What Are AWHONN’s Staffing Standards? Birth And Delivery Nurses Explain Why They Matter

Preparing to welcome a new baby is an exciting time, often filled with baby showers, nesting galore, as you ready for your bundle of joy and the all-important process of contemplating baby names.

What’s not likely to be top of mind, however, is the nursing staffing levels in the labor and delivery unit where you’ll give birth (if you’re planning to deliver in a hospital).

But registered nurse Jen Hamilton, author of the book “Birth Vibes: Stories and Strategies for an Empowered Birth,” said that’s the one question expecting parents should get to the bottom of.

In a recently posted Instagram reel (which has since gone viral, racking up more than 100,000 likes), Hamilton explains that the nurse-to-patient ratio is key to having safe care during delivery.

More specifically, Hamilton said the crucial question that expecting individuals should ask: Does the hospital adhere to the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) Staffing Standards?

“There are going to be hospitals that are pissed that I’m making this video, but I hope it goes far and wide,” Hamilton explained in the reel. “You need to know whether the hospital that you’re going to give birth in follows AWHONN’S safe staffing standards. I did not say guidelines, I did not say suggestions, I said standards.”

But what exactly are AWHONN’s staffing standards? And is there anything parents can do to ensure those standards are met? Here’s what you need to know.

AWHONN is a Washington, D.C.-based professional association that works to empower and support the nurses who care for pregnant individuals and newborns.

The organization’s Standards for Professional Registered Nurse Staffing for Perinatal Units address the nurse-to-patient ratios deemed necessary to ensure safe and appropriate staffing levels for “high-quality care and the best possible outcomes.”

“The Safe Staffing Standards are a tool for hospitals to ensure they have enough nurses to safely care for the unique mix of maternity and newborn patients they have at any particular time,” Jennifer Vanderlaan, Ph.D., MPH, CNM, assistant professor at the University of Nevada, Las Vegas (UNLV) School of Nursing and a certified nurse-midwife, tells HuffPost.

So, what is the appropriate staffing level for high-quality care during labor and delivery?

Hamilton stresses in her Instagram reel that your nurse should be attending to no more than two patients. (And that’s on a bad day.) “I’m grateful that I’m blessed to work in a place where most of the time I have one patient. On a crazy day, two,” she said. “But never, ever more than that. But there are hospitals that are getting away with egregiously unsafe staffing because no one is holding them accountable.”

No matter the work environment, having more tasks than you can reasonably accomplish is problematic, often leading to mistakes or items falling through the cracks. Now apply that critical, and sometimes touch-and-go process of labor and delivery, and it should be abundantly clear why the nurse–to–patient ratio is so important.

“When nurses have too many patients, critical nursing care can be missed and complications may not be recognized early enough to prevent harm,” Vanderlaan said.

During labor, a nurse is monitoring the health of two patients — the parent and the baby — while also keeping abreast of labor progress and often managing high-alert medications, such as those used to induce labor.

Nurses caring for a patient immediately after a cesarean, meanwhile, are tasked with monitoring recovery from surgery (including recovery from anesthesia), while also providing immediate postpartum care. And separately, nurses who provide postpartum care are watching for signs of life-threatening conditions like hemorrhage, while also helping new parents learn to feed and care for their newborn, continues Vanderlaan.

“These are all complex nursing tasks, and nurses must be given enough time to complete them to ensure the health of both patients,” Vanderlaan explains.

There are also instances when labor becomes especially intense, and a patient needs a nurse focused primarily on them, according to Juliana Parker, RN, founder of Nurse Core Triage, Inc.

“A nurse’s workload can change fast during labor, especially if any complications come up,” Parker said. “If nurses are taking care of too many patients at once, important warning signs can be missed, like changes in blood pressure, changes in the baby’s heart rate and heavy bleeding. With enough staffing, nurses can catch these problems early and act quickly.”

There are a variety of reasons why nursing staffing levels may vary in a hospital, ranging from cost-cutting measures to workforce shortages. And that’s not all.

“One of the biggest barriers to safe staffing is that insurance reimbursement for maternity care is inadequate compared to other conditions and sometimes does not cover the actual cost of providing safe care,” explains Vanderlaan. “This is part of the reason we are losing rural birth hospitals.”

Another barrier to adequate nurse staffing levels is that some hospitals are expected to make a profit for their investors. “In these hospitals, nursing staff are treated as a cost to be minimized,” continues Vanderlaan.

“The Centers for Medicaid and Medicare Services have worked to change hospital incentives through quality measurement and value-based purchasing that put a dollar value on nurse-sensitive outcomes,” adds Vanderlaan. “Unfortunately, inclusion of maternity nurse-sensitive outcomes has been slower than other types of outcomes.”

And here’s a key and often overlooked takeaway amid this whole issue: When nursing levels are consistently not what they should be, it can impact the nurses themselves as well, said Sara Holt, CNM, MS, CAS, PMH-C, midwife and owner of Byenveni Baby, a midwife support and education community.

“Nurses become demoralized because they know that they’re not offering the type of care that patients want and deserve due to personnel shortages,” Holt said. “It’s a terrible feeling to work your hardest and still feel like you were not set up to successfully give patients and families the care they need and deserve.”

Holt’s point is especially timely. In case you missed it, a massive nurses strike has been taking place in New York City, the largest in the city’s history. Some 15,000 nurses in New York’s Mount Sinai, Montefiore and New York-Presbyterian systems walked off the job in response to a variety of issues, not the least of which is the New York State Nurses Association’s (NYSNA) efforts to maintain the safe staffing standards it won three years ago.

Hospital representatives, meanwhile, have said that the nurses’ demands are unreasonable.

The reality is that patients do not have much power over a hospital’s staffing levels. But there are some steps you can take to advocate for yourself.

• Understand the hospital environment that you’re stepping into. You can achieve this goal by asking questions in advance. “Although it may feel uncomfortable, it sends a message that you expect a high level of care during your stay,” Holt said. “For many institutions, hearing from patients and communities carries more weight than getting input from staff midwives, OBs and nurses.”
• If you’re worried about staffing or your care, it’s OK to speak up. If during the course of your delivery, you have concerns, don’t be shy about expressing them. “Ask to talk to the charge nurse, which is the nurse in charge of the unit,” Parker said. “If you still feel concerned, ask for the nursing supervisor.”
• Have a support person who can advocate on your behalf. Because labor can be tiring and intense, you may not always have the strength to ask a lot of questions. But having a partner or support person who knows how to speak up for you can really help, advises Parker.

Once labor and delivery are over (or before they begin), there’s another step you can take to help advocate for staffing standards at the hospitals in your community: Advocate for safe hospital staffing laws in your state.

Ultimately, however, Holt said it’s important for families to give the same — or greater — thought to choosing a place of birth as they would to any major life decision.

“Asking about metrics such as cesarean and episiotomy rates can offer insight into the culture of a birthing unit,” Holt said. “Hospital ratings and maternity care data are publicly available through the Leapfrog Hospital Survey Results, which allows families to compare outcomes across facilities. These questions can always be asked of your birth provider as well. If a family feels uncomfortable with their provider or hospital system, it is absolutely worth exploring other options.”