How Is the Pandemic Changing Perinatal Health Care?

How Is the Pandemic Changing Perinatal Health Care?

Nearly overnight, the coronavirus pandemic transformed health care, including perinatal care. Anticipating more and more COVID-19 patients, hospitals needed to create space quickly, both to manage the influx of patients with the disease and to protect non-infected patients from exposure to SARS-CoV-2. 

Elective surgeries were postponed, telehealth was utilized when possible, and some care shifted to outpatient with remote monitoring. One procedure that cannot easily be postponed or managed remotely, though, is childbirth. And, even as the pandemic dramatically reshapes parents’ expectations of labor and delivery, the coronavirus is colliding with crises already affecting pregnant people and new mothers and parents — namely, the struggles to reach families in rural or remote areas and to prevent the unnecessary perinatal deaths of Black people. 

Melicia Escobar, BSN, MSN, CNM, WHNP-BC, believes this complex moment in perinatal health is one that nurse-midwives, trained to move through a crisis without forgetting the client at the heart of it, are more than prepared to meet.

“This is why I think midwife leaders are really shining in this time, across academic settings, medical centers, and home birth, because that’s what we’re trained to do,” said Escobar, a certified nurse-midwife (CNM) and Women’s Health Nurse Practitioner (WHNP) and Clinical Faculty Director of Georgetown University’s Nurse-Midwifery/Women’s Health Nurse Practitioner (WHNP) and WHNP programs.

Intentional support provided by antenatal and birthcare providers is essential in helping families navigate this crisis safely — as well as mitigating the potential negative effects that the pandemic’s social and economic consequences could have on perinatal health in the future. Escobar considers these and offers action steps for supporting people in pregnancy, birth, and the postpartum period below.

Parents Have Fewer Choices About the Birth Experience

Parents tend to have better outcomes when they are empowered to make choices about their birth experiences.

“Having options, offering unbiased guidance around those options, and listening to clients is so important. When people have options for where to birth, for example, and have information to weigh pros and cons, then they know where they should be,” said Escobar. “They know what’s best for them. We just need to listen.”

Consider one key decision parents have to make: Where should I have my baby? In many rural areas, birthplace options can be extremely limited. Options for out-of-hospital care may be rare, and even when parents choose an in-hospital birth, they may only have one hospital accessible to them. Some community hospitals have discontinued childbirth services completely, forcing families who want a hospital birth to travel elsewhere for care.

A CNM in Philadelphia, Escobar set the scene of the pandemic’s early days: “People were afraid of being in a hospital and exposing themselves or their babies to COVID-19. They were also afraid of being subject to hospital policies around COVID-19.”

At some hospitals, one such regulation was limiting the number of support people allowed at the birth to reduce providers’ exposure. But there was an unintended — and unjust — effect, as detailed in the article Reflecting on Equity in Perinatal Care During a Pandemic” in Health Equity: “A policy of no support persons unduly impacts marginalized communities and implicitly reinforces the ‘sacrificial’ or expendable status of Black and Indigenous parents, who have long borne the consequences of mistreatment and abandonment in their health care experiences.”

Protecting parents’ options and respecting their choices surrounding the birth experience is especially important in a crisis. Options should be safe, affordable, and respectful — in other words, a real choice among viable options.

Whether because of the coronavirus or biased, inequitable treatment, “it’s not really a choice when going into the hospital can mean real and present danger,” said Escobar. 

Existing Risk Factors May be Compounded, Especially for Women of Color

Prior to the pandemic, pregnant and birthing people in marginalized groups were already at higher risk of complications and death, as explored in [email protected]’s “How Does Race Impact Childbirth Outcomes?” Perinatal mortality rates are highest among Black women in the United States, as are rates of severe maternal morbidity (SMM), an unexpected labor and delivery outcome that may create significant short- or long-term consequences for a person’s health.

~42 non-Hispanic Black women die for every 100,000 live births, compared to 13 deaths for non-Hispanic white women.

Source: CDC, “Pregnancy Mortality Surveillance System.” 

70 cases of severe maternal morbidity events, or “near misses,” occur for each maternal death of a non-Hispanic Black woman.

Source: The American Journal of Managed Care, “Racial Disparities Persist in Maternal Morbidity, Mortality and Infant Health.” 

~4.2% of non-Hispanic Black women experience a severe complication compared to 1.5% of white women.

Source: American Journal of Obstetrics and Gynecology, “Site of Delivery Contribution to Black–White Severe Maternal Morbidity Disparity.

Some methods of adapting perinatal care during the pandemic could ultimately prove harmful to women, especially women of color, according to the aforementioned Health Equity article. For example, some providers have encouraged early inductions and elective cesarean births (C-sections) to help manage “hospital census and staffing.”

However, these procedures often require increased close contact between patients and providers, increasing the risk of COVID-19 exposure. They can also lead to longer inpatient stays, creating a higher risk for both the parent and newborn.

“Given that women of color already experience higher rates of inductions and cesareans, these policies are likely to further exacerbate the disparities in outcomes,” wrote the article’s authors.

Traumatic Experiences Could be Worsened

Most people bring trauma into the childbirth experience to begin with, said Escobar. COVID-19 adds another layer of stress and fear that may be especially difficult for expectant parents.

~14% of women are affected by perinatal depression.

Source: National Institute of Mental Health, “Perinatal Depression.”

~9% of women experience post-traumatic stress disorder (PTSD) after childbirth caused by real or perceived trauma during delivery or postpartum.

Source: Postpartum Support International, “Postpartum, Post-Traumatic Stress Disorder.”

“Then there’s a second-layer trend where Black, Indigenous, and people of color (BIPOC), who already enter our health system at a disadvantage and carrying trauma, are forced to choose between COVID risk and a system in which they perceive they are unsafe due to racism and bias,” said Escobar. 

“The baseline level of trauma that Black birthing people in particular experience is already so high,” said Escobar. “For folks opting to stay out of care or seeking out-of-hospital birth, it is very easy to understand the logic: Why compound things by introducing either of those two factors, COVID risk and racism?”

Action Steps for Supporting Maternity Care in a Crisis

Giving birth during a pandemic can be traumatic, especially for those who have already experienced trauma in the health care system. With trauma comes fear. When people — both patients and providers — start making fear-based decisions, “that’s when you start getting bad outcomes,” Escobar said.

Still, a negative outcome does not have to be traumatizing. Listening to and empowering the person giving birth can transform the experience.

“There have been clients I’ve been caring for in labor who have had obstetric emergencies, like postpartum hemorrhages or uterine abruptions, where my perception was that the experience was probably traumatic for them,” said Escobar. 

However, the patient tells a different story. “Afterwards when we were debriefing, one of those clients said to me, ‘Thank you so much. That was the most empowering experience in my life,’” she said.

Escobar believes the difference between a traumatic childbirth and a difficult but empowering birth is in listening, sharing information, and partnering together even in the midst of a crisis. When people start from a place of listening to expectant parents, they can understand and mitigate their fears. They can work through or around the trauma to comfort the client and overall have better outcomes — even if the childbirth has scary elements.  

Below, find suggestions for providers, loved ones, and communities to better listen to and support women in pregnancy and the postpartum period during the coronavirus pandemic and beyond.

  • Adopt a midwifery-model mindset: Nurse-midwives are trained to stay calm in difficult births, create an action plan, and move through it with the person “always centered,” said Escobar.
  • Treat listening and clear communication as vital clinical skills, as essential as doing an abdominal exam or listening to heart sounds.
  • Listen to the client, especially when discussing sexual health history and gender-based violence.
  • Find ways to communicate empathy and understanding, even through layers of personal protective equipment.
  • Share information and partner with the patient throughout their care, especially in potentially traumatic childbirths.

How Can Family and Friends Offer Support When You’re Expecting During a Pandemic?

Reserve judgement and honor the choices being made around childbirth and coronavirus precautions.

  • Before visiting, ask about the family’s comfort level with in-person interactions, and again, avoid adding to guilt or shame about those precautions.
  • Identify alternative ways to be helpful, such as sending takeout meals or taking care of yard work. 
  • Consider offering financial support if needed and requested. 
  • Check in if you have not heard from a new parent and ask if they need any support or reassurance.
  • Extend compassion to new parents in the postpartum period. “We’re going through a collective grieving process in this pandemic,” said Escobar. “That loss and fear juxtaposed with the excitement, joy, and hardship of transition is a really intense nexus.” 

How Can Communities Better Preserve Perinatal Health in a Crisis?

Develop a trauma-informed approach to every level of health administration and public service, from intake to birth to discharge. 

  • Consider how to address the external factors that affect pregnant and birthing people and their families. “Pregnant people don’t exist in isolation,” said Escobar. “They have housing needs, they have food needs.”
  • Have a nurse-midwife on maternal health leadership teams. “It improves outcomes, culture, and patient satisfaction everywhere,” said Escobar.
  • Create policies that make perinatal care more holistically accessible. For Escobar, accessibility includes having a hospital to go to that offers safe, effective, unbiased, and respectful care.

Citation for this content: [email protected], the online Women’s Health Nurse Practitioner program from the Georgetown University School of Nursing & Health Studies

Share This: 7 Ways to Support Nurses in 2021

Share This: 7 Ways to Support Nurses in 2021

During the initial US COVID-19 outbreak last March, Americans were quick to express their gratitude to nurses and other healthcare workers. Entire cities boosted the spirits of HCWs with nightly cheers, and individuals as well as businesses sent meals to hospitals, offered nurses personal assistance, and performed other acts of kindness. Now, with the massive fall/winter surge courses around the nation, people are searching for new ways to support nurses’ efforts in fighting the pandemic. If anyone asks you what they can do to support nurses, here are some suggestions from our friends at the Georgetown University School of Nursing and Health Studies (see the full story here):

1. Follow the Recommended Safety Protocols

Help slow the spread of the virus by taking the recommended precautions, such as staying home, wearing masks in public, and following social distancing guidelines. And make time to get a Covid-19 shot ASAP when the vaccines become available to the general public later this year!

2. Donate Blood

In times of crisis, there is often a shortage of blood donations, which can be critical for patient care. Organizations like the Red Cross offer information on how to find local blood drives. 

3. Contact Community Leaders

Find out if groups in your area are making efforts to help. For example, local churches have done cloth mask drives to help minimize the use of personal protective equipment (PPE) outside of health care settings, Arceneaux said.

4. Be an Advocate

Supporting policies and legislation that benefit public health and health care professionals can help make a lasting change. The American Nurses Association provides a regularly updated list of COVID-19 issues and information on how to help.

5. Get a Flu Shot

As we enter flu season, health care experts are worried about managing influenza outbreaks while also continuing to treat COVID-19 patients, Arceneaux said. Taking this precaution can help slow the spread of the influenza virus.

6. Ask a Nurse

If you know a nurse or health care worker, consider asking them if they need assistance with running errands, child care, or other tasks.

7. Give to Charities that Support Covid Frontliners

Several nonprofit organizations are currently raising money for COVID-19 initiatives. To make sure your money will be put to good use, look up the groups you are considering on Charity Navigator or Charity Watch to verify their trustworthiness.

Organizations That Aid Healthcare Workers

CDC Foundation Coronavirus Emergency Fund 

This crowdfunding effort by the CDC Foundation was established to direct funds toward purchasing medical supplies, increasing lab capacity, deploying emergency staffing, providing support to vulnerable communities, and other health care efforts related to COVID-19.

Center for Disaster Philanthropy (CDP) COVID-19 Response Fund 

This fund aims to “support containment, response, and recovery activities.” In addition to providing services for vulnerable populations and small businesses, the fund also supports frontline health care workers by providing PPE and deploying emergency medical teams.

COVID-19 Frontline Health Worker Fund 

Intrahealth International is behind this initiative, which directly supports health care professionals. Services provided through donations vary, as they strive to address the current and ever-changing needs of medical teams.

COVID-19 Solidarity Response Fund for WHO 

The World Health Organization is raising money to address the pandemic in many ways through their partnerships. In addition to accelerating COVID-19 research, WHO also offers PPE and other supplies to health care workers.

GlobalGiving Coronavirus Relief Fund 

Organized by GlobalGiving, this fund supports health care workers by sending medical teams to communities in need of additional help, as well as providing supplies such as masks and ventilators to hospitals. The fund additionally serves vulnerable community members affected by the pandemic.

Project HOPE 

Project HOPE focuses primarily on providing PPE to health care workers, delivering training on how to care for COVID-19 patients, and deploying health care workers to medical facilities in need of additional staffing.

Citation for this content: [email protected], the online MSN program from the School of Nursing & Health Studies

Vaccinating a Nation: a Guide to Achieving Herd Immunity

Vaccinating a Nation: a Guide to Achieving Herd Immunity

Flu season is here, and the media is filled with news about the new Covid vaccines, so this is a good time to have a sort of primer explaining the profound importance of vaccination for communities as well as individuals. [email protected], the online MSN program from the School of Nursing and Health Studies at Georgetown University, has kindly allowed DailyNurse to share their guide to the essentials of herd immunity and tips for addressing vaccine-hesitant patients and loved ones.

What is Herd Immunity?

Also referred to as “community immunity,” herd immunity is a public health term used to describe a case in which the potential for person-to-person spread is significantly reduced due to the broader community’s resistance against a particular pathogen.

A Glossary of Important Vaccination-Related Terms

  • Active immunity: Immunity as a result of the body’s antibody creation after exposure to disease-causing pathogens, either through natural infection or vaccination.
  • Herd immunity threshold: Also called the “critical vaccination level,” this is the approximate percentage of a population that needs to be vaccinated in order to reach herd immunity status.
  • Immunity: Resistance to a particular pathogen, or disease-causing bacteria, through antibodies.
  • Inactivated vaccine: A vaccine using a killed form of the disease-causing germ. This vaccine usually requires multiple doses over time to form immunity. Examples include the DPT and Hepatitis A vaccines and the flu shot.
  • Live attenuated vaccine: A vaccine using a weakened form of a germ to produce an asymptomatic infection and generate an immune response similar to a natural infection, without sickness. Examples include the MMR and chickenpox vaccines.
  • Natural infection: Contraction of a disease through person-to-person transmission or interaction with disease-causing bacteria.
  • Passive immunity: Immunity after receiving disease-fighting antibodies from an external source.
  • R0 (Pronounced “r-naught” or “r-zero”): The reproductive number of a disease that describes the average number of additional cases a single infected person creates.
  • Subunit vaccine: A vaccine using a component of the germ (such as a specific protein) to produce an immune response. This vaccine does not contain a live germ. Examples include the shingles and HPV vaccines.
  • Vaccine: A controlled simulation of natural infection meant to trigger antibody creation that helps fight against the disease later, without sickness.

Why is Herd Immunity So Important?

When enough community members are immune to a virus so that it inhibits spread, even those who are not vaccinated will be protected. The “herd” collectively provides insulated safety to all members, which is important for those who are too high-risk for certain vaccinations.

For example, the yellow fever vaccine should not be administered to individuals who are pregnant, have a weakened immune system, or have specific allergies, according to the CDC guidelines on who should not be vaccinated.

For these individuals, it is important that their community has built an immune response to the yellow fever so they are not at risk of infection and transmission. Individuals who are too high-risk to get a vaccination are often more likely to contract the illness and experience serious symptoms.

Some other reasons why people cannot get certain vaccinations include:

  • Age
  • Allergies
  • Pregnancy
  • Recent blood transfusion
  • Underlying medical conditions like lung or heart disease
  • Weakened immune system

Elke Jones Zschaebitz, DNP, ARPN, FNP-BC, and faculty member at Georgetown University School of Nursing & Health Studies, likens herd immunity to a perimeter fence that ensures the safety of the broader community.

“It’s like a little nuclear circle,” she said. “So that our babies that can’t get vaccinated yet, or our pregnant mothers, or our elderly with immune systems [that] are not as robust, or people who have certain kinds of conditions that they don’t have the correct immunity, will have protection from the active pathogen that could possibly harm or kill them.”

HITs and R0s: the Science Behind Herd Immunity

Herd Immunity: Few vaccinated
Herd Immunity: all vaccinated

In a community where no one is immune to a virus, a disease can spread rapidly and lead to an outbreak. As individuals acquire immunity, either through infection or a vaccine, the disease spreads more slowly because fewer people can pass it on.

In a community where enough members are vaccinated, the disease will stop spreading because the virus will not be able to find susceptible hosts.

The herd immunity threshold (HIT) varies depending on a variety of epidemiological factors. The primary consideration is the infectiousness of a disease. Infectiousness is measured by the Basic Reproduction Number or reproductive ratio—often referred to as R0 (“r-zero”). R0 refers to the number of cases expected to occur on average in a susceptible population as a result of infection by a single individual at the start of an epidemic before widespread immunity starts to develop. So if one person develops the infection and passes it on to two others, the R0 is 2. Herd immunity helps R0 drop below 1.

Here are some examples of R0s for a few well-known infectious diseases:

  • Measles R0: 12-18
  • Polio R0: 5-7
  • Ebola R0: ~2

Numbers for COVID-19’s R0 vary —The Atlantic reported a range of about 1.5 to 5.5 in February, while more recent estimates from WHO place COVID-19’s R0somewhere between 2 and 4 (PDF, 2 MB). The herd immunity threshold (HIT) varies depending on a variety of epidemiological factors. The primary consideration is the infectiousness of a disease, often referred to as R0; herd immunity helps R0 drop below 1.

“The higher R0 is, you’ll have to have really, really high [levels of active immunity], or it’s still transmissible and the vulnerable population will still get it,” Thompson-Brazill said.

A September 2020 report in Nature Reviews Immunology expects COVID-19’s herd immunity threshold to equal 67%, if R0 is 3. However, the Government Accountability Office cautioned researchers against reaching any conclusions regarding herd immunity for COVID-19 (PDF, 276 KB), as much is still unknown about the contagiousness of the disease.

The Role Clinicians Play in Herd Immunity and Vaccination

Zschaebitz and Thompson-Brazill have years of experience in various health care settings— from travel clinics and trauma units to international research. Some of the ways that clinicians increase herd immunity and vaccination include:

  • participating in global research to genotype communities and help produce viable vaccines.
  • administering vaccines so patients can stay up-to-date on immunization schedules and travel requirements.
  • educating patients on the importance of vaccination and specific information related to different vaccines.

How to Talk to Patients, Family, and Friends About Vaccination

Thompson-Brazill shared her experience speaking with patients who are vaccine-hesitant and said she has learned that one of the roles clinicians play in herd immunity is educating patients about why vaccines are safe and normative for society.

Zschaebitz also shares the importance of herd immunity with patients — often through the retelling of her own experiences genotyping Maasai tribal women for an HPV vaccine.

“We were interested in preventing deaths of cervical cancer because in certain countries women just die,” she said. “Declining a vaccination is sort of a first-world problem because people in other nations would walk for miles to get what we have and what we take advantage of.”

Thompson-Brazill and Zschaebitz’s tips for speaking to vaccine-hesitant friends and family:

Tip #1: Avoid pointed questions that could make someone defensive.

Instead of: “Why wouldn’t you get the shot?” Try: “What about the shot worries you?”

Tip #2: Use storytelling as a way to share your experience.

Instead of: “I can’t believe you are not going to vaccinate your children” Try: “I chose to vaccinate my kids because…”

Tip #3: Refer people to credible, reliable sources.

Instead of: “Why would you believe that? That’s just a hoax!” Try: “The CDC has a lot of useful information about vaccines and potential risks. Have you read what they have to say?”

Tip #4: If you do not know how to respond, recommend an expert who does.

Instead of: “I can’t talk to you about this; we will never agree.” Try: “Have you shared your concerns with your clinician? They will be able to answer your questions.”

A Herd Immunity FAQ

Is it possible to achieve herd immunity without a vaccine?

Because the herd immunity threshold is so high, achieving herd immunity without a vaccine is unlikely, according to the American Lung Association. The likelihood depends on the disease’s R0, because a lower threshold would be easier to reach naturally. However, the severity of a disease could also mean that many individuals in a community would succumb to a disease before broader immunity is obtained.

Is herd immunity effective against all diseases?

No, not all diseases can be overcome with herd immunity. For example, herd immunity cannot be achieved for Clostridium tetani, the bacteria that causes tetanus. Although infection is avoidable via individual vaccination, the “herd” cannot provide protection. For example, the immunity of others will not prevent an individual from contracting tetanus after stepping on a rusty nail.

Can you still get the flu after a flu shot?

It is possible to become sick with a strain of influenza that the vaccine was not developed to protect against. However, the CDC says that the flu vaccine will minimize the severity of symptoms among those who do get sick. Other reasons someone could experience flu-like symptoms after getting a flu shot include contracting a different respiratory illness and exposure to the flu virus shortly before vaccination.

Why do I need to get vaccinated for diseases we already have herd immunity for?

Some immune responses weaken over time, which is why booster shots are so important. Additionally, vaccine refusal can lead to waning community immunity. For example, in 2019, measles outbreaks in New York and Oregon threatened the United States’ 20-year measles elimination status, according to a press release from HHS on measles outbreaks in 2019.

Is immunity from a natural infection stronger than immunity from a vaccination?

Yes. Natural immunity, the result of antibody production after natural infection, is often more effective and longer-lasting than acquired immunity via a vaccine. However, acquired immunity is safer. Some cases of natural infection can be accompanied by symptomatic illness and severe outcomes like pneumonia, liver cancer, and even death, according to an article on vaccine safety from the Children’s Hospital of Philadelphia.

Reliable Information Sources on Vaccines and Vaccination

Both Zschaebitz and Thompson-Brazill recommend using nationally recognized, expert-led sources to learn more about vaccines, like the CDC, FDA, and NIH. Some of the additional resources available include:

  • CDC Immunization Schedules External link : The CDC-recommended vaccination series and timing schedule for children, adolescents, and adults.
  • The CDC Yellow Book External link : A set of travel health guidelines, including country-specific vaccine recommendations and requirements.
  • Questions About Vaccines, FDA External link : The FDA’s collection of information regarding specific vaccines and approvals.
  • The Power of Herd Immunity, TED Talk by Romina Libster External link : Health researcher Romina Libster tells the story of an H1N1 outbreak in her town and the role of herd immunity.
  • Vaccines by Disease, HHS External link : Vaccine-specific answers to questions such as: “Why is this vaccine important?” and “What are the side effects of this vaccine?”

DailyNurse would like to thank the Georgetown School of Nursing and Health Studies and the [email protected] site for allowing us to share this guide.

Improving Health Care Access for Survivors of Sexual Assault

Improving Health Care Access for Survivors of Sexual Assault

One in three women and one in four men have experienced sexual violence involving physical contact during their lifetimes,   according to the Centers for Disease Control and Prevention (CDC).

This type of trauma necessitates urgent medical attention from trained sexual assault nurse examiners (SANEs), yet several obstacles exist for many survivors seeking specialized care. Depending on where a patient lives, he or she may have to travel for hours to reach the closest available provider for a Sexual Assault Forensic Exam (SAFE)—a critical step when a patient decides to report an assault to the police.

“It’s very much a deterrent for rural [residents] to drive for any type of care,” said Pamela Biernacki, DNP, FNP-C, faculty member in the Georgetown University School of Nursing & Health Studies.

The gap in availability of appropriate care after a sexual assault affects the safety of individuals, families, and entire communities. Health care professionals, hospitals, and community stakeholders can make substantial improvements to SANE access.

How Many Sexual Assault Programs Are There?

Despite the prevalence of sexual assault in the United States and the need for SANE intervention, access to specialized care for survivors of sexual assault is limited.

The International Association of Forensic Nurses (IAFN) database of SANE providers shows that there are approximately 959 programs that offer SANE care in the United States. IAFN reported that 1,732 nurses are SANE-certified through their organization. Of those, about 1,230 nurses are SANE-A certified, meaning their training is specific to adults and adolescents, and 502 are SANE-P certified and are trained to work on pediatric cases. Approximately 381 nurses are dual-certified.

Nonetheless, research has shown that survivors lack access to SANE care. The GAO’s 2018 report on sexual assault and the availability of forensic examiners (PDF, 191 KB) reflects data from six states that served as case studies. Officials in every state reported a shortage of SANE providers, especially in remote areas.

“When you’re in some place like rural Colorado, the closest SANE program could be 100 miles away, or a two-hour drive,” Metz said.

Distance is a significant barrier for an individual who wants to be treated by a sexual assault nurse examiner. In a 2018 hearing on the availability of forensic exam kits in hospitals, New Jersey Congressman Frank Pallone Jr. explained that a survivor “must avoid bathing, showering, using the restroom, or changing clothes, or else risk damaging the evidence before it can be collected.”

These recommendations for preserving evidence leave an individual who lives hours away from a SANE-designated hospital with the options of experiencing extreme discomfort, risking the outcome of their forensic exam, or not receiving specialized care at all.

Why Do Survivors of Sexual Assault Need Specialized Care?

There were 298,410 instances of sexual assault in the United States in 2016, as reported by the Bureau of Justice Statistics (BJS) in a bulletin on criminal victimization (PDF, 669 KB). When any survivor seeks medical attention after an assault, they require care that addresses both physical and mental health needs.

Triage often includes a forensic exam, which calls for specific equipment and a clinician trained to perform the assessment. To facilitate this specialized form of care, some hospitals have implemented SANE programs that staff certified nurses to treat patients who require interventions tailored to their needs.

Designated SANE facilities can make a difference in a survivor’s path to healing, from initial assessment and treatments to the criminal justice process (should the survivor choose to report the assault). Studies have shown that exams performed by SANEs “may result in better physical and mental health care for victims, better evidence collection, and higher prosecution rates,” according to a 2018 report on sexual assault and the availability of forensic examiners (PDF, 191 KB) from the U.S. Government Accountability Office (GAO).

The BJS bulletin indicates that many survivors choose not to involve law enforcement—nearly 80% of sexual assaults went unreported in 2016. However, receiving treatment from a SANE who fully understands a patient’s trauma can make a substantial difference regardless of whether the results of a forensic exam are used in a criminal case, said Michelle Metz, SANE Coordinator for Denver Health.

“Sometimes we’re the only person who is there,” said Metz. “We bear witness. We may be the only person who says ‘I’m really sorry this happened to you. I’m really glad you came in.’”

Survivors who are unable to seek care from a SANE-designated facility may miss out on the diagnosis and treatment of infections related to their assault, as well as emotional support and guidance on follow-up care, Biernacki said.

SANEs often provide survivors with referrals for mental health care. In her professional experience as a Nurse Practitioner, Biernacki has observed the long-term effects of trauma, particularly among women, who did not seek out treatment immediately following their assault.

“Depression and anxiety are the [most prominent conditions] I’ve seen,” she said. “It also comes out in physical symptoms, like insomnia or gastrointestinal problems.”

In some cases, women Biernacki spoke with did not fully understand their experiences, underlining the need for more education on what to do in the case of a sexual assault. “Until we had a conversation after taking a thorough sexual history, [patients] didn’t realize that what they experienced is considered assault,” she said. “They had not identified it or did not want to take that emotional step to say, ‘Yes, I have been sexually violated.’”

What is Causing the Shortage of Sexual Assault Nurse Examiners?

A number of factors contribute to the scarcity of SANE care. Based on its findings, the GAO report on sexual assault and the availability of forensic examiners (PDF, 191 KB)  cited the following three barriers to increasing accessibility to SANE programs.

Lack of Funding from Hospitals or Law Enforcement

Officials in five of the six states selected for the GAO case study reported that obtaining support from key stakeholders was a challenge. For example, hospitals may be reluctant to cover the costs of training SANEs or to pay for SANEs to be on call.

Limited Availability of Training

In five of the six states, officials reported that the diminished availability of classroom, clinical, and continuing education training opportunities is a challenge to maintaining a supply of SANEs.

Clinical training requires 300 hours of SANE-related practice, which can be an obstacle in areas with smaller patient populations, said Jennifer Pierce-Weeks, CEO of IAFN.

“It can be difficult to establish competency as a sexual assault nurse examiner,” she said. “The classroom training [can be done] online or in-person, but then there is the clinical training which can be difficult for people to access.”

Low Retention Rates of SANEs

Officials in one of the selected states reported that while the state trained 540 SANEs during a two-year period, only 42 were still practicing in the state at the end of those two years, as a result of the challenges of working in a trauma setting.

Metz explained that in her experience as a SANE coordinator, “the nurses who do this work last either 18 months or more than five years.”

Biernacki emphasized the importance of establishing support systems for nurses, something that can be a challenge for smaller, rural facilities.

“With any type of burnout, it is about having that support,” she said. “But since [nurses] typically do work alone or have very few individuals that are part of that team, how do they build that sense of community and support?”

What Can Be Done to Improve Health Care Access for Survivors of Sexual Assault?

In the effort to improve access to sexual assault care, Biernacki said a good first step is to further educate student clinicians about this specialty and the needs of sexual assault survivors.

“We have started teaching about human trafficking, and we talk about intimate partner violence,” she said. Delving further into sexual assault would be an appropriate next step.

While there are currently no national guidelines on sexual assault care, state and federal legislators are making efforts to make this type of health care more accessible.

In 2018, the Survivors’ Access to Supportive Care Act (SASCA) was re-introduced in the U.S. Senate to expand access to qualified examiner services and develop national standards of care for survivors of sexual assault.

Further Information

Below are links to recent stories on SANE shortages in states across the US:

“It’s a public health crisis:” Indiana short-staffed on sexual assault nurse examiners

Lack of SANE nurse causing issues for sexual assault investigations (Michigan)

Critical shortage of sexual assault nurses in Ohio poses risk to survivors, cases

There’s a shortage of Sexual Assault Nurse Examiners (Pennsylvania)

There’s a Shortage of Sexual Assault Nurse Examiners in Kentucky

Not enough nurses have specialized training to handle rape victims in Missouri

Full-length article originally published by [email protected]

What Women Need to Know About Strokes and Heart Attacks

What Women Need to Know About Strokes and Heart Attacks

When it comes to serious health conditions like heart attack and stroke, women are more likely to be misdiagnosed and receive delayed care.

When Andrea thought she was having a heart attack and called 911, the emergency medical technicians told the 35-year-old Nashville, Tennessean that she was likely just experiencing a bout of anxiety.

“They made me walk outside, down my driveway to the ambulance. They never turned on the sirens or lights and stopped at every light on the way to the hospital,” she told Today. 

But Andrea was not having an anxiety attack. As it transpired, she had experienced a major cardiac event as a result of a spontaneous coronary artery dissection, an uncommon condition that can affect otherwise healthy individuals.

“The delay in my care caused me to have severe heart damage and heart failure that I am still living with” she said.

While Andrea’s condition is rare, her experience with emergency care is not.

How Are Symptoms of Heart Attack and Stroke Different for Women?

Myocardial infarction, more commonly known as a heart attack, occurs when the flow of oxygen-rich blood to the heart becomes blocked.

A heart attack can be caused by:

  • The full or partial blockage of an artery as a result of plaque buildup.
  • A coronary spasm, in which a coronary artery tightens and cuts off blood flow.

When people think of what a heart attack looks like, they might picture a man grabbing his chest and describing severe pain that extends to his arm. While chest pain is the most notable symptom of a heart attack, many people— especially women—experience less common symptoms. This can lead to misdiagnosis and delayed treatment among female patients.

According to a study from the American Heart Association, almost 62% of women who have a heart attack experience more than three non–chest pain symptoms, compared to 54.8% of men.

The perception of which symptoms necessitate emergency care can lead women to delay seeking treatment, which affects their chances of surviving and making a full recovery.

“If you have nausea and vomiting and back pain or epigastric pain … the first thing that comes to you is not, ‘I’m having a heart attack,’” said Melissa Frisvold, PhD, CNM, APRN, faculty at the Georgetown University School of Nursing & Health Studies.

Symptoms of Heart Attack in Women

Heart Attack warning signs in women
Less commonly known symptoms of heart attack that are more likely to be present in women than men include stomach pain, shortness of breath, chest palpitations, nausea, and dizziness.

Strokes in Women

For women, perceptions of symptoms can also affect treatment of another life-threatening condition — stroke.

Sometimes referred to as a “brain attack,” a stroke occurs when a clot blocks the blood supply to the brain or when a blood vessel in the brain bursts.

The three main types of stroke include:

  • Ischemic stroke — occurs when blood flow through the artery that supplies oxygen-rich blood to the brain becomes blocked.
  • Hemorrhagic stroke — caused by a leak or rupture in an artery in the brain.
  • Transient ischemic attack — also referred to as a “mini-stroke,” blood flow to the brain is blocked for a short time and is a warning for future stroke.

In a 2014 study, researchers found that women experiencing a stroke were at greater risk than men for misdiagnosis in the emergency room. They attributed this disparity to a greater frequency of non-classic stroke presentations, including headache and dizziness.

In addition to having misinformation about symptoms of heart attack and stroke, Frisvold said women may also put more focus on other health risks that they perceive to be bigger threats.

According to the Centers for Disease Control and Prevention’s (CDC) report on the leading causes of death in 2017 (PDF, 2.4 MB), women were most likely to die as a result of heart disease, followed by cancer. Stroke was the fourth-leading cause of death in women.

“Women worry about breast cancer or cervical cancer,” she said. “But heart disease is the leading cause of death in women, not breast cancer or cervical cancer.”

Symptoms of Stroke in Women

Stroke symptoms in women
Less commonly known symptoms of stroke that are more likely to be present in women than men include loss of consciousness, general weakness, difficulty breathing, disorientation, sudden behavioral change, hallucination, nausea or vomiting, seizures, and hiccups.

How Does Gender Affect Health Care?

The misdiagnosis of heart attack and stroke in women is part of the larger issue of gender bias in health care. This stems in part from how clinical research has been performed in the past, which informs how care is provided to patients today.

In a research study on sex bias in clinical studies from the Allen Institute for Artificial Intelligence, researchers examined medical research from 1993 to 2018 and found that women were underrepresented subjects in the research of several health conditions, including cardiovascular health.

“Women worry about breast cancer or cervical cancer, but heart disease is the leading cause of death in women.”

— Melissa Frisvold, PhD, CNM, APRN

Another study on clinical trials for stroke treatment indicated that women were underrepresented in such trials, leading to suboptimal conclusions for women in outcomes and stroke care delivery.

Implicit Bias Affects Treatment

The exclusion of marginalized groups, including women and people of color, may lead to a misunderstanding of the many ways a health condition can present itself and how it should be treated. “Medical bias,” a term for that disparity, refers to cases in which an individual may receive different care from a provider who is unknowingly acting on partial judgement.

The consequences of implicit bias in health care can be seen in how women receive treatment in comparison to men in life-threatening situations.

For example, a study from the American Stroke Association found that in cases of ischemic stroke, men were more likely than women to receive ultrafast Alteplase administration, a clot-busting drug that helps restore blood flow to the brain.

Additionally, in the aforementioned study from the American Heart Association, 53% of young women (aged 18 to 55) said their health care provider did not think their initial symptoms were heart-related, compared to only 37% of young men who said their provider got it right. These researchers also discovered a pattern in female patients who said they hesitated to seek help because they feared being labeled a hypochondriac.

Because of women’s experiences with the health care system, these biases may affect how women view their own health.

How to Advocate for Women’s Health

Women, their family members and friends, and even bystanders can take steps to help improve care for heart attack and stroke. From advocating for oneself in the emergency room to taking action when someone is in distress, the following resources are a starting point for women’s health advocacy.

How to Communicate With Your Clinician

Women sometimes express that they do not feel heard by their provider when sharing health concerns. Frisvold provided these tips for self-advocacy:


Another person can provide support, ask additional questions, and help navigate the treatment process.


If an individual believes he or she may be having a heart attack or stroke, being prepared to specifically communicate all concerns to the clinician can help.


Engaging in dialogue allows for an individual to push back in a way that is specific and may help a provider check his or her bias.


“When you talk to somebody who had a heart attack, they [often] say, ‘I just knew something wasn’t right, but I just kept trying to downplay it.’ You’re better off going to the emergency room and finding out it was nothing than to err the other way,” Frisvold said.

How Bystanders Can Take Action in Health Emergencies

When another person appears to be experiencing a heart attack or stroke, there are steps you can take to help improve the chances of a positive health outcome:


“Time is of the essence,” Frisvold said. “Those early moments are critical. Take steps early in the process to improve the health outcome of the person experiencing a heart attack or stroke.”


If a stroke is suspected and the person is conscious, the bystander should ask what symptoms the individual is experiencing so the information can be shared with emergency responders if the situation worsens and requires an advocate.


A 2019 study showed that women were less likely to receive CPR from a bystander than men. This step is critical in cases where an individual goes into cardiac arrest while waiting for emergency response. If the bystander has no CPR training, a 911 dispatcher can provide guidance in performing chest compressions.

Resources for Further Reading

Citation for this content: [email protected], the online MSN program from the School of Nursing & Health Studies

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