Reproductive Health During COVID-19

Shoshana Aronowitz is a National Clinician Scholar Program Fellow at the University of Pennsylvania and family nurse practitioner. Charlotte Scott is a family nurse practitioner. Shawana Moore is the program director of the Women’s Health-Gender Related nurse practitioner program at Jefferson University, a women’s health nurse practitioner, and on the Board of Directors of NPWH. All provide primary and reproductive healthcare in Philadelphia.

With at least 50% of US citizens on ‘stay at home’ orders, many of us have experienced one of the impacts of these policies: decreased access to non-emergency healthcare. While out-patient clinics are generally considered life sustaining and are allowed to remain open, many have limited their hours or have completely ceased in-person visits. This is due in part to fewer scheduled appointments as patients are socially distancing and staying in, and because clinics are protecting the health of their staff as the supply of personal protective equipment (PPE) runs dangerously low. Clinics must now determine which services are deemed “essential” and will continue to be offered and which are “non-essential” and can be put on hold. Especially controversial–at all times and especially now–are reproductive and sexual healthcare services.

Limits on Already Limited Access

Many areas of the country are already severely lacking in reproductive healthcare, and COVID-19 related ‘stay at home’ orders threaten to limit this access further. Within the past few months, the Attorney Generals of both Texas and Ohio have announced that abortions are “non-essential” services and must be halted immediately. Orders like these threaten the health and safety of people who may become pregnant in the next few months, as well as those who are already pregnant and are awaiting scheduled procedures. The medical community is in agreement: abortion is an essential component of comprehensive healthcare. We do not know how long ‘stay at home’ orders will last and restricting access to abortion during this time will mean that many people will be too far along in their pregnancies to receive the procedures when clinics are allowed to reopen.

Unplanned and Unwanted Pregnancies Could Spike

As reproductive healthcare providers, we are worried about what will happen to our patients if they lose access to these services. Increased time spent at home during COVID-19 lockdowns may lead to a “pregnancy boom.” While many people will be excited about these pregnancies, others will be unplanned or unwanted, especially if access to contraception is reduced due to clinic closures. Financial hardship caused by lost jobs and wages could make the prospect of an unplanned pregnancy especially stressful for many families. Additionally, increased isolation may make some individuals especially vulnerable to sexual coercion and violence during this time. Many individuals in sexually coercive or abusive relationships rely on discreet birth control options like injectable Depo-Provera or intrauterine devices (IUDs), which may be harder to access as clinics close.

How Reproductive Healthcare Can Continue

‘Stay at home’ orders do not need to mean that access to reproductive health services will be totally lost; much of this care can be provided over the phone. Providers can easily refill birth control prescriptions and emergency contraception (the morning-after pill) electronically. Even medication abortions–which involve the prescription of two medications to induce abortion safely at home–can be provided by telehealth and clinics providing this service have 24 hour on-call providers available to answer questions or direct patients to in-person care in the case of emergencies. Access to these services must be expanded to serve all who need them.

Nurse Practitioners Are a Valuable Resource

Some states, such as Vermont, Washington, Oregon and Maine (to name a few) allow nurse practitioners and physician assistants to provide medication abortions. These provisions help increase access to reproductive healthcare by ensuring that more clinicians are available to serve patients. During a time when fears about healthcare professional shortages abound, allowing for expanded scope of practice for nurse practitioners and physician assistants can reduce some of the stress on an already taxed system. New York, Wisconsin and West Virginia are among the few states that have temporarily suspended all practice agreement requirements for nurse practitioners during COVID-19. Other states (Pennsylvania, Louisiana, Missouri, to name a few) have temporarily waived selected practice agreements requirements during this time.

This is Essential Healthcare

The proliferation of telehealth services can help ensure that reproductive healthcare remains accessible–but not all care can be provided over the phone. Surgical abortions require in-person visits and must not be deemed “elective” procedures. Medication abortion is not the right choice for all patients, and policies limiting access to in-clinic procedures put these individuals in danger. We call on state policy makers to consider the essential nature of reproductive healthcare services and not to limit their provision during these uncertain and scary times. We call on healthcare providers offering telehealth to make sure that patients who need contraception have access. For everyone else wanting to help: donations to the Women’s Medical Fund assist people with financial hardships afford the reproductive healthcare they need.

Graduating During COVID-19

The below is written by Megan Dorsey, MS, RN, C-EFM, a 2020 graduate of The Ohio State University College of Nursing.  Randee L. Masciola DNP, APRN-CNP, WHNP-BC is the Lead Faculty in the College’s WHNP Specialization Track and provided assistance with this blog.

2020 began with so much promise for my life. I was a few short months from completing my Master’s in Nursing in the Women’s Health Nurse Practitioner (WHNP) specialization track at The Ohio State University (OSU). My days focused on preparing for class, clinicals, graduation plans, applying for jobs, and organizing my life. I also managed a part time job as a registered nurse in a Labor, Delivery, Recovery, and Postpartum (LDRP) unit, along with an extremely active two-year-old daughter. COVID-19 was not really on my radar. Then March came and everything changed.

As March began,  I was seeing pregnant women and doing annual gyn exams in clinicals. Within days, all clinicals were cancelled through the end of the spring semester. Fortunately, my 500 hours of patient-facing direct care were already complete, but I still needed to finish my clinicals and obtain the required 600 hours to sit for the exam. I had job interviews coming up for WHNP opportunities beginning in July – I needed to graduate on time. To say I was stressed was an understatement – I was losing my mind!

Thankfully, The College of Nursing faculty quickly created alternative options. Opportunities in leadership with our advanced health assessment course, case study simulation, wellness partners to fellow graduate students, and providing telehealth phone triage with a local OB/GYN office rounded out my required clinical experience. They also transitioned our remaining classes online and touched base weekly via Zoom. As students, we were all short tempered and irritated, but at least we knew we were being heard.

Throughout this time, I knew my greatest risk of COVID-19 exposure would be at work – a LDRP unit in a metropolitan area – and my biggest fear was bringing anything home to my family.  I often work as the charge nurse and it is our responsibility to triage. First person in the room means being the first person at risk for exposure. We were frequently competing with the ER for Personal Protective Equipment (PPE).

Additionally, Information and policies were constantly changing and even though we knew it was in the best interest of the patients and staff, it was frustrating and stressful. The hardest change was limiting patients to one support person.  And, while most patients were wonderful, it was challenging to help them understand that the policies in place were for their safety, and all the healthcare workers and the patients that came in after.

About two weeks into the pandemic, my biggest fear came to be: I developed a cold, which worsened into a persistent, dry cough. I learned that I had a potential exposure and was taken off work and referred for testing. I spent a large part of that first night crying, banishing myself to the basement away from my family.  I was terrified I had exposed them. I started thinking about becoming sicker, being hospitalized, and my daughter getting sick. How would we care for her if I were sick?  What if my husband or daughter became sick and I couldn’t be with them at the hospital? Would they be scared and alone? The mom worry and guilt spiraled out of control. I was tested the next day and waited 2 days for results. Thankfully as each day continued, I felt better, so the worry dissipated. My test finally came back negative.

I returned to work on my next shift, which created another hurdle: childcare. All daycares were closed, and my husband and I had to find a way to care for our daughter while also doing our own jobs and schoolwork. After long discussions, we asked my in-laws to come stay with us and help care for her. We are so lucky to have them, and I will never be able to repay them for putting themselves at risk.

When clinicals were cancelled, I was so anxious about graduating on time. But eventually, due to the frequent communication and support from our school, my academics became the thing I was the least stressed about. The most helpful new opportunities were the telehealth hours and case-based simulations with fellow students via Zoom, and the wellness partnership training. As we return to our new normal, I feel like the wellness course should be offered to all nurse practitioner students. It really taught me how to talk with patients, not at them.

Another huge support system was my fellow students. We had group text messages to voice our frustrations but also to make each other laugh and check-in. We would have Zoom meetings after our kids were asleep just to vent and talk about challenges at work – we work in three different hospital systems, so it was helpful to hear how things were going at different sites. My managers were also a huge help at my job; they kept us informed but also fought for our safety, something I heard was lacking at other facilities. My greatest support system, though, will always be my family. My parents, brothers and sisters-in-law have been exquisite by sending masks, doing drive by visits, and making me laugh. My biggest cheerleader through this has been my husband. We have found new ways to balance life, but also focused on putting each other first.

This has been a trying time for a graduating WHNP, but as my Dean would say, it has been character building. When the stay at place order began, I did not know if I was going to graduate, be separated from my family, or get sick myself. I have gone through every emotion possible, but I have come out stronger and more compassionate. I have spent more time with my family, which helped me solidify my priorities. I am incredibly sad that I will not be able to walk at graduation, but I am hopeful for a future graduation ceremony.

I think COVID will change health care for the better – our scope of practice, how we interact with patients, and what we deem acceptable in our own work-life balance. I will forever be honored for graduating from The Ohio State University, especially during this historic time. Through it all, my faculty not only prepared me to step into this new role as a WHNP, but how to be innovative to find evidence-based solutions to challenges. I look forward to the day I will talk to younger nurse generations about this time, and how we came through stronger and more prepared for the next crisis.

Self-Care, Stress, Anxiety, and COVID-19

April is Alcohol Awareness Month. This post was developed in coordination with  the Center for Behavioral Health Research and Services (University of Alaska, Anchorage), American College of Nurse-Midwives, Association of Women’s Health, Obstetric and Neonatal Nurses, and National Organization on Fetal Alcohol Syndrome.

These past weeks have brought rapid change as our families, our communities, and our profession respond to the COVID-19 pandemic. For many of us – and our patients – these changes have brought increased stress and anxiety and we may be looking for new or additional ways to cope. Some of us or our patients may increasingly turn to alcohol or food, so this week we would like to focus on some healthier coping strategies that you can integrate into your daily routine or share with your patients.

First and foremost, we should acknowledge that self-care is important for all of us – if we are not looking after ourselves, how can we do our best caring for others and supporting their needs? Our first inclination may be to indulge in some favorite snack foods or a glass of wine, but there are many healthier alternatives. Self-care can take many forms – whether it’s taking a little time to read a new book or re-read an old favorite, enjoy a long shower or bath, watching a favorite TV show, or practicing yoga.

Self-care should also include looking after our emotional and social health. Stay connected with loved ones, even if we cannot meet them in person, by taking some time to text, phone, or video call. Share those silly memes and a laugh. If you’re feeling anxious, try some positive calming activities such as steady breathing and muscle relaxation, yoga or tai chi, or listening to your favorite music. There are even some apps available to walk you through meditation practices, such as iCalm, Headspace, and many others.

We should also take care of our physical health. If you are at home, this might include committing to getting up and moving regularly. This doesn’t have to take long – even ten minutes every hour or two can help! Maybe try something new, do some dancing to your favorite music (great fun if you’re also at home with children!), or try a free YouTube work out. If you’re able, get out and go for a walk – but remember the 6-foot rule (or 10 feet if you’re running!)

Maintaining our physical health should also include ensuring that we – as much as possible – maintain a healthy diet. Try putting together a container of fruit and veggies to munch on through the day – carrots, cucumber, apples, and mandarins make good and easy snacks, especially for children. And while it may be tempting to eat junk food, drink that extra cup of coffee or two, or finish the day with a large glass of wine, remember that good sleep is important self-care as well and vital for maintaining a healthy immune system. While alcohol may seem to help you sleep, we know that can negatively impact the sleep quality and immune system functioning, so try some other relaxing alternatives such as a soothing herbal tea.

Remember, we’re all in this together – and we’ll get through this together.

Join Us in Anaheim for our Annual Premier Women’s Healthcare Conference

Is more continuing education your 2020 new year’s resolution? What about sharing your knowledge with you peers? Doing more networking with your fellow WHNPs?

This year, NPWH will host the 23rd Annual Premier Women’s Healthcare Conference in Anaheim, CA from October 15th – 18th.

If you’re wondering what happens at our conferences, take a look at highlights from our 2019 conference:

  • More than 1,000 practitioners and other champions of women’s health joined us in beautiful Savannah, Georgia.
  • Attendees enjoyed the plenaries, breakout sessions, and workshops designed to keep all of us up on the leading edge of guidelines and clinical knowledge. All sessions were also uploaded to the NPWH website so you can watch any you might have missed.
  • We recognized the following inspirational award winners:

Inspirations in Women’s Health

Kelly Ellington, DNP, APRN, WHNP-BC, RNC-OB (Policy): Following her own battle with breast cancer, Dr. Ellington turned adversity into advocacy surrounding awareness and funding for equal access to 3D mammography for women across the state of North Carolina, including securing funding to provide free mammography services to women in at-risk communities.

Marianne Hutti, PhD, WHNP-BC, FAANP, FAAN (Education): Dr. Hutti, an NPWH member since 1998, developed the first women’s health nurse practitioner program in the state of Kentucky.

Ludrena Rodriquez, DNP, WHNP-BC, RNC-OB, C-EFM (Practice): Dr. Rodriguez, a 22-year service veteran, developed and implemented the Army’s first same day walk-contraception clinic at a robust OBGYN clinic, with the hopes of the initiative being fully adopted at all Army facilities worldwide.

Fran Way Legacy Award

Mary Rubin, PhD, WHNP-BC, FAANP: Dr. Rubin has been practicing as a clinician, educator, and researcher for almost 50 years. She is the pioneer of the role of the nurse colposcopist.

  • Our Student Leadership Program returned, giving 10 WHNP students from around the country the chance to attend the conference and gain invaluable experience. We look forward to these students being a part of NPWH for years to come! We also encourage everyone to share this opportunity with their students next year – the application process will open next summer.
  • We offered a conference mobile app for the third year in a row! We heard your feedback from past years and were pleased to offer the slide presentations to download within the app.
  • We celebrated Gay Johnson, our CEO, as she announced her retirement after 23 years of service to our organization.

Check out the video below to hear from conference attendees on why you should join us in Anaheim!

We’re accepting research abstracts for presentation now! We hope to see you in Anaheim!


NPWH Board Chair on The International Year of the Nurse and Midwife

The following is written by Diana M. Drake, DNP, APRN, WHNP, FAAN, Clinical Associate Professor at the University of Minnesota School of Nursing, and new Chair of the NPWH Board of Directors.

As the new NPWH Board of Directors Chair (2020–2022), I am eager to start a new role, new year, and new decade with auspicious beginnings. The World Health Organization (WHO) has designated 2020 the International Year of the Nurse and the Midwife in honor of the 200th birthday of Florence Nightingale. Nurses and midwives are the essential and often only healthcare providers in communities around the world, constituting more than 50% of the health workforce in many countries. WHO reports the world needs 9 million more nurses and midwives to achieve universal health coverage by 2030. We look forward to WHO’s first State of the World’s Nursing report to be launched this year.

At the NPWH organizational level, we will work to sustain a national dialogue throughout the year in celebration of the nursing profession and highlight ways to increase investment in it and alleviate obstacles. To get involved and bring the campaign message to your workplace and community, visit the WHO website for the campaign toolkit.

Heralding the start of the Year of the Nurse and the Midwife, I would like to recognize two nurse contemporaries of Florence Nightingale and Clara Barton who despite unimaginable obstacles made significant contributions to our profession. They are Mary Eliza Mahoney (1845–1926) and Susie King Taylor (1848–1912).

Mary Mahoney was the first African American to work as a professionally trained nurse in the United States, graduating from the nursing program at the New England Hospital for Women and Children in 1879. She created the National Association of Colored Graduate Nurses, which had a significant influence on eliminating racial discrimination in the profession and later merged with the American Nurse Association.1

Susie Taylor, born into slavery she later escaped, was the first African American army nurse and an educator and activist. She tended the 33rd US Colored Troops during the Civil War and authored the only account of Civil War experiences by an African American woman. She became president of the Women’s Relief Corps in 1893.2

As we honor Florence Nightingale this year, we reflect that by today’s standards she would have been the world’s first advanced practice nurse. She has been quoted as saying: “For we who nurse, our nursing is something which, unless we are making progress every year, every month, every week, we are going back. No system shall endure which does not march.”

NPWH has exhibited steady progress since its inception in 1980. We continue to “march” to expand the impact of our organization and profession through strategic priorities that support nurse practitioners in women’s health, from providing student mentoring and leadership programs for the next generation of nurse practitioners to the NPWH-led BOlder Women’s Health Coalition, a pioneering effort that partners healthcare and public policy to meet the needs of aging women. Using the United Nations Sustainable Development Goals, we will “march” to address women’s and gender-related health and wellness. These will also guide us in empowering women and girls by reducing inequalities through supporting marginalized populations and working to change the impact of social determinants of health and planetary health in our role as healthcare providers.3

Essential to all is assessing where our profession is within the current context of turbulent political, global events and a rapidly changing healthcare landscape. We can then begin to understand clinical practice and organizational obstacles that are perhaps uncomfortable to address. To create more conscious systems and organizations that provide greater inclusivity and representation, structural change is inevitable. Diversity expert Howard Ross has written about organizations being ruled by normative behaviors that we never question just because they seem so normal. He expresses the need to “pause to see ourselves and our organizations in action,” allowing us to recognize how some of it can cause unintended negative repercussions.4

At the NPWH conference in Savannah in October 2019, we paused to see ourselves. Themes of implicit bias, inclusivity and equity, underrecognized and undertreated mental health disorders, disproportionate maternal mortality rates for women of color, threats to women’s reproductive rights, and access to care were highlighted. We addressed these issues and discussed how healthcare providers could work toward intentional, active change. One WHNP student attendee wrote:

“I left Savannah feeling empowered, motivated, and excited to start transitioning into my role as a Women’s Health Nurse Practitioner over the next year. I appreciated the inclusion of content that may be seen as controversial to some. As care providers, it is very important for us to make ourselves uncomfortable in order to learn about the experiences of others. I was very impressed and grateful for the content incorporated throughout the conference on maternal mortality rate disparities, especially in Black and Native American women, and for the material discussing implicit bias and systemic racism. These are things we often don’t want to think about unless it directly affects us. To see NPWH starting these conversations and disseminating this information to leaders in our field gives me great hope that we may spark change together in women’s healthcare and in our communities across the nation.”

Her words affirm what NPWH does best: We are “the nation’s leading voice for courageous conversations about women’s health.”5 We are the professional organization making the invisible visible in women’s health through including topics such as sex trafficking, women’s sexual health, nonbinary and transgender healthcare, gender-affirming hormone therapy, and new models of care for older women. We empower women to be strong decision makers in their own health. We influence by being highly visible and connecting with organizations that share our values to raise public awareness, publishing a professional journal and position statements, providing continuing education resources, and recognizing significant contributions to the profession through national awards. We are committed to educating our members and the public on issues impacting women’s health and to the perspective of health described in the UN’s Sustainable Development Goals. As we embark on this decade, let’s review our organization’s mission, vision, and values and consider how, as a community of women’s healthcare providers, we can strategically move forward with controversial and courageous conversations.


  1. Ridgeway S. Mary Mahoney, the First African-American Graduate Nurse. Working Nurse. 2019. https://www.
  3. United Nations.
  4. Ross H. Everyday Bias: Identifying and Navigating Unconscious Judgments in Our Everyday Lives. London: Rowman and Littlefield; 2014.
  5. NPWH. NPWH mission, vision, and values. https://www.




National Nurse Practitioner Week: Shedding Light on the Important Role of Women’s Health Nurse Practitioners

The following was written by Shawana Moore, DNP, MSN, CRNP, WHNP-BC. Dr. Moore is an Assistant Professor and Women’s Health-Gender Related Nurse Practitioner Program Director at Jefferson University, as well as an NPWH Board Member. 

November 10th-16th, 2019, we celebrate nurse practitioners (NPs) throughout our nation for their extraordinary contribution to society. NPs care for individuals throughout the lifespan, lead healthcare systems, advocate for health policies, educate communities, and transform the way healthcare is delivered.

Statistics on Nurse Practitioners

  • 270,000 practice in the United States1
  • 99.1% have graduate degrees2
  • Hold prescriptive privileges, including controlled substances, in all 50 states and the District of Columbia3

Specialty Areas Available for Nurse Practitioners

There are multiple speciality areas in which nurse practitioners can obtain their primary certification. These include:

  • Women’s Health Nurse Practitioner
  • Neonatal Nurse Practitioner
  • Primary Care Pediatric Nurse Practitioner
  • Acute Care Pediatric Nurse Practitioner
  • Adult-Gerontology Nurse Practitioner
  • Adult-Gerontology Acute Care Nurse Practitioner
  • Family Nurse Practitioner
  • Psychiatric Mental Health Nurse Practitioner

Women’s Health Nurse Practitioners

Women’s health nurse practitioners (WHNPs) specialize in the care of women and make up 2.7% of NPs.3 According to a survey completed by the American Association of Nurse Practitioners in 2018, most WHNPs work as part of a private practice obstetrics and gynecology group.3 WHNPs practice in inpatient and outpatient settings, treating individuals throughout their lifespan and caring for their sexual and reproductive health care needs with a comprehensive and holistic approach.

Practice Settings Include:

  • Urogynecology Clinics
  • Gynecology-Oncology Clinics
  • Primary Care Clinics
  • Obstetric Triage Units
  • Breast Health Centers
  • Obstetric and Gynecology Outpatient Clinics
  • Postpartum Units
  • Reproductive Endocrinology & Infertility Offices
  • Maternal-Fetal Medicine Clinics
  • Sexual Health Practices
  • Women’s Correctional Facilities
  • Family Planning Clinics or Health Centers

Areas of Care Include:

  • Well-women care
  • Adolescent health
  • Contraceptive counseling
  • Transgender health
  • Pregnancy testing
  • Infertility treatment
  • Sexual Health
  • Male reproductive and sexual health
  • Menopausal health
  • Sexually transmitted infection treatment
  • Screening for general health problems
  • Breast health
  • Gynecological cancers


Facts about the women’s health nurse practitioner can be found on Nurse Practitioner & Women’s Health Nurse Practitioner Practice Facts website provided by the National Association of Nurse Practitioners in Women’s Health. Additionally, WHNP Guidelines for Practice and Education – 7th Edition, provides information on the role of women’s health nurse practitioners, practice guidelines and competencies of practices.

During this special week, let us take time to recognize the significance of nurse practitioners and the role of women’s health nurse practitioners in improving the lives of women everywhere.



  1. AANP National Nurse Practitioner Database, 2019.
  2. American Association of Colleges of Nursing (AACN). (2019). 2018-2019 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. Washington DC: AACN.
  3. 2018 AANP National Nurse Practitioner Sample Survey.

Preconception Care for Women Living with Diabetes

Brandee Newsom, APRN, BC-ADM, CDE, works in Perinatal Diabetes Management at the High Risk Pregnancy Center in Las Vegas, NV. She recently presented on gestational diabetes at our 2019 Annual Conference. She shares the below for World Diabetes Day.

Today is World Diabetes Day, and as practitioners who care for women, it’s critical that we understand how this condition impacts our patients -especially when it comes to pregnancy. Diabetes can be managed before and during pregnancy to mitigate the risks to our pregnant patients and improve their long-term health. I offer this overview of screening and diagnosis, risk reduction, and the latest developments so we can provide quality care to our patients with diabetes and those at risk for diabetes.

By the Numbers

People living with diabetes are 2-4 times more likely to develop and die from heart disease or stroke. These risks are greater in women than men. Women with diabetes who become pregnant have a 10-20% chance of developing preeclampsia in addition to other adverse outcomes.

Screening and Diagnosis

If a woman is at risk for diabetes, she should be screened and counseled regarding risks. This includes women with the following risk factors:

  • Overweight/obese
  • Family history of diabetes
  • High blood pressure
  • High cholesterol
  • PCOS
  • Ethnicities including Native American, Asian, African American, Hispanic, or Pacific Islander
  • History of gestational diabetes or macrosomic fetus
  • History of cardiovascular disease

Criteria for the diagnosis of diabetes:

  • Fasting plasma glucose ≥126 mg/dL (fasting is defined as no caloric intake for at least 8 hours)*
  • 2-h PG ≥200 mg/dL during 75-gram glucose tolerance test*
  • A1C ≥ 6.5%*
  • Random plasma glucose ≥200 mg/dL, with classic symptoms of hyperglycemia or hyperglycemic crisis

(* In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate test samples.)

Any woman with diabetes should be counseled if they are planning a pregnancy within the year. Referring to an MFM specialist for a prepregnancy consultation can be helpful in this regard especially if the patient has additional risk factors.

Reducing Risk for Mother and Baby

In optimizing the health of the mom, fetus and neonate, the two key modifiable risk factors are BMI and blood sugar levels. In this regard:

  • Prior to pregnancy their A1C should be less than 6.0%, their fasting blood sugar should be <95 and 2 hours after meals should be < 120.
  • For optimal risk reduction, they should try and achieve a normal BMI prior to conception.
  • Excellent nutrition and a moderate amount of exercise are imperative for improving health, especially for women with diabetes planning a pregnancy. Referrals to a certified diabetes educator (CDE), a Registered Dietitian (RD/RDN), or a Diabetes Program that is recognized by the ADA/AADE can help.
  • They should have screening for any diabetes related complications such as heart disease, hypertension, or thyroid disease.
  • They should be up to date on their eye and dental exams as well as their vaccinations.
  • Since these patients have an increased risk of neural tube defects, they should be taking folic acid at least 3 months prior to conception and through the first trimester.

New Developments

The link between diabetes and cardiovascular disease has been well established. Even gestational diabetes and future risk of cardiovascular disease has been well studied. Interestingly, a retrospective study published in the Lancet in March 2019 shows that the risk of cardiovascular disease extends into the non-diagnostic range for glucola results. It showed that for each 1 mmol/L increment in the glucose challenge test result was associated with a 13% higher risk of cardiovascular disease after adjustment for age, ethnicity, income, and rurality. This relationship persisted after excluding women with gestational diabetes.

Helpful Resources

ACOG committee opinion on Prepregnancy Counseling

ACOG FAQ handout for patients Healthy Pregnancy for Women with Diabetes

The Provider’s Role in Domestic Violence Awareness

The below was written by Heidi Fantasia PhD, RN, WHNP-BC. Dr. Fantasia is an Associate Professor at the Solomont School of Nursing, University of Massachusetts – Lowell, and a member of the NPWH Board of Directors

Every October, we recognize Domestic Violence Awareness. Since 1981, this month has been used to promote awareness, support victims, and advocate for a world with less physical, sexual, and emotional violence. The Violence Against Women Act was passed in 1994 and there has been much progress toward providing services for victims of violence and also holding perpetrators responsible for their actions.

What is domestic violence?

Domestic violence, also known as intimate partner violence, is a broad term that can include many different types of actions. Abusive behavior is used as a way to control a partner, and control is a central component of the relationship. These behaviors can include things such as control of finances, limiting outside relationships, isolation from family and friends, verbal threats or intimidation, stalking, coerced sexual encounters, control over reproduction, and physical violence. Although violence can occur in any relationship and can be committed by both men and women, the most common scenario is a male perpetrating violence toward a female partner.

How common is domestic violence?

It is estimated that 1 in 4 women will experience some type of intimate partner violence during their lifetime and this number may even be higher due to underreporting. Although all women could potentially be exposed to violence in a relationship, younger women between the ages of 18 and 24 are at greatest risk. Relationship violence, combined with a gun in the home, increases the risk of homicide by 500%. Intimate partner violence accounts for 15% of all violent crimes.

Why do women stay in abusive relationships?

Leaving an abusive relationship can be extremely dangerous for the woman. They often face blame for staying and disbelief that violence occurs when they don’t end the relationship. When the abuser senses that he or she is losing control over their partner, the violence can escalate and the risk for lethality increases. If there are dependent children, then leaving becomes even more complex because not only does the woman need to consider her own safety but the also the safety of her children. The process of leaving can be lengthy, and often women have experienced economic control and isolation as part of the abuse. Therefore, they may lack the financial resources and social capital necessary to support themselves and their children independently and safely.

What can health care providers do?

Screen for Intimate Partner Violence

One of the most important things health care providers can do is screen women for intimate partner violence when they present for care. Due to fear, stigma, concern about being believed, and shame, women may be reluctant to initiate a conversation with their provider. Asking women directly if they have experienced violence increases disclosure rates and allows for identification of women who need services and support. Direct questions such as “Have you ever experienced physical, sexual, or emotional violence or threats from a partner?”, “Are you currently afraid of someone?” and “Do you feel safe in your relationship and at home?” are examples of questions that are clear and concise. Letting women know that these questions are asked of everyone prevents women from feeling singled out or targeted due to any sociodemographic factor. These questions also convey that the topic is important and allows for dialogue about safety and physical and emotional health.

Discuss Healthy Relationships

Another important role for health care providers is to discuss healthy relationships, especially with adolescent women who might be starting to navigate dating and romantic partnerships. Inquiring about the nature of the relationship with open-ended questions such as “Tell me about your partner” or “Are you happy in your relationship?” provides an opportunity to gain insight into behaviors that might indicate abuse or the potential for abuse. Adolescent women may perceive constant messages, wanting to know where they are and who they are with, and displays of jealousy as care and concern and not controlling behavior.

Direct Patients to Support Services

All health care providers should be prepared to offer support and assistance to women who disclose violence. It’s important to have a current list of support services in the geographical area, including law enforcement contacts, shelters, safe houses, counseling, and legal aid (especially pro bono). Women may want to end a relationship but need time to arrange housing, finances, transportation and other necessary items. Performing a lethality assessment and helping women to craft a safety plan is essential, especially if there are guns or other weapons in the home.


Although awareness of intimate partner and domestic violence has increased steadily, there is still much more progress to be made. Continued efforts to recognize relationship violence as a prevalent public health issue will help decrease victim blaming and normalize conversations about best strategies for prevention.

Don’t Let Breast Cancer Awareness Fade After October

The below is written by Rachel Gorham, MSN, WHNP-BC, AGN-BC. Ms. Gorham is on the NPWH Board of Directors. 

October is Breast Cancer Awareness Month – an opportunity for us all to focus on breast cancer and its impact on those affected by the disease in our community. Even though we’re nearing the end of the month and the pink ribbons are being put away, we cannot let our dedication to educating patients fade.  Here’s a refresher on the breast cancer risks, symptoms, and screening guidelines that all WHNPs should be familiar with in order to support our patients.

Breast Cancer Statistics

First, let’s talk about who is affected by breast cancer:

  • Advancements in breast cancer screening and treatment has improved survival rates dramatically since 1989. According to the American Cancer Society an estimated 268,000 women will be diagnosed with invasive breast cancer, and 62,930 women will receive a diagnosis of noninvasive breast cancer in 2019. ACS reports over 3.1 million breast cancer survivors in the United States.
  • About 1 in 8 U.S. women (about 12%) will develop invasive breast cancer during her lifetime.
  • A man’s lifetime risk of breast cancer is about 1 in 883. Approximately 2,670 new cases of invasive breast cancer are expected to be diagnosed in men during 2019.
  • For women, breast cancer death rates are higher than those for any other cancer, besides lung in the U.S.
  • African American women under the age of 45 are more commonly diagnosed with breast cancer than white women.
  • A woman’s risk of developing breast cancer doubles if she has a first-degree relative (mother, sister, daughter) who has been diagnosed with breast cancer.
  • About 5-10% of breast cancers can be linked to gene mutations inherited from one’s mother or father.
  • The most significant risk factors for breast cancer are gender (being female) and age (growing older).

Risk Factors  

We know a lot about what factors can influence a patient’s risk of breast cancer:

Age: The risk of breast cancer increases with age. At 20 years, the probability of developing invasive breast cancer in the next 10 years is .06%, or 1 in 1,732. This means that 1,732 women in this age group can expect to develop breast cancer. Age 70, the probability of developing invasive breast cancer in the next 10 years is 3.84%, or 1 in 26.

Family history of breast cancer: Up to 10% of breast cancers are due to specific mutation in single genes that are passed down in a family. Multi-gene testing for hereditary forms of cancer has rapidly altered the clinical approach to testing at-risk patients and their families. Genes associated with hereditary breast cancer includes the following that could potentially be included in a multi-gene test: BRCA1, BRCA2, ATM, BARD1, CHEK2, PALB2, TP53, PTEN, STK11, and CDH1.

Personal history of breast cancer: Women who have previously been diagnosed with breast cancer are at risk of developing it again, either in the same breast or the other, and is higher than if you never had the disease.

Dense breast tissue: Dense breasts are common, particularly in younger women. Dense breasts are associated with an increased breast cancer risk and may impair detection, however there are currently no recommendations for screening women with dense breasts.

Exposure to estrogen: Estrogen stimulates breast cell growth and exposure to estrogen over long periods of time, without any breaks, can increase the risk of breast cancer. Some of the risk factors that are nonmodifiable include: starting menstruation before the age of 12, going through menopause after age 55, and exposure to estrogen in the environment.

Body weight: Women who become overweight or develop obesity after menopause may also have a higher chance of developing breast cancer, possibly due to increased estrogen levels. High sugar intake may also be a factor.

Alcohol consumption: A higher rate of regular alcohol consumption appears to play a role in breast cancer development.

Radiation exposure: Prior exposure to high-dose therapeutic chest irradiation at age 10-30 years may increase the risk of developing breast cancer later in life.


It’s critical that patients know and regularly look for these symptoms, and that they know to talk to us if they experience any:

  • new lump or lumpiness, especially if it’s only in one breast
  • a change in the size or shape of your breast
  • a change to the nipple, such as crusting, ulcer, redness or inversion
  • a nipple discharge that occurs without squeezing
  • a change in the skin of your breast such as redness or dimpling
  • an unusual pain that doesn’t go away.
  • peeling, flaking, or scaling of the skin on the breast or nipple

Finally, providers need to know the difference in screening guidelines for women with average breast cancer risk, and women whose risk is above average:

Screening Guidelines for Women at Average Breast Cancer Risk

(no symptoms of breast cancer, no history of breast cancer or atypia, no family history of breast cancer, no suggestion of a hereditary cancer syndrome, and no history of mantle radiation)

  • Women between the ages of 25 and 40 should have an annual clinical breast examination.
  • Women 40 and older should have an annual mammogram in addition to an annual clinical breast examination.
  • Ultrasound may be recommended for women with dense breast tissue.
  • All women should consider performing a monthly self-breast exam beginning at age 20 and become familiar with their breasts so they are better able to notice changes.

Screening Guidelines for Women at Above-Average Breast Cancer Risk

  • A clinical breast exam every six months starting no later than ten years before the age of the earliest diagnosis in the family (but not earlier than age 25 and not later than age 40).
  • An annual mammogram starting no later than ten years before the age of the earliest diagnosis in the family (but not earlier than age 25 and not later than age 40).
  • Possible supplemental imaging (for example, with ultrasound) for women with dense breast tissue.
  • Possibly alternating between a breast MRI and a mammogram every six months, as determined by your provider.


We have made so many advancements in screening for and treating this cancer. As providers, we need to keep up the fight, stay vigilant, and support our patients with the best care we can provide.

September is Fetal Alcohol Spectrum Disorders Awareness Month

The below is written by NPWH Director of Publications, Beth Kelsey, EdD, APRN, WHNP-BC, FAANP

As nurse practitioners providing healthcare for women, we have the opportunity to be leaders and champions in a campaign to prevent alcohol use during pregnancy and fetal alcohol spectrum disorders (FASDs). Our patients trust us to provide client-centered care that includes providing facts, being respectful of their individual needs and concerns, and supporting them in making informed decisions that will promote healthy pregnancy outcomes. Sometimes the conversations we have with patients about alcohol use during pregnancy are easy, sometimes they are difficult. As nurse practitioners we are equipped to have the conversation whether easy or difficult.

Call to Action

According to CDC data, only 17 percent of pregnant women reported that their healthcare provider talked with them about alcohol use. We have to do better. Our role must go beyond individual patient care. Educate colleagues, offer to speak at community events on the topic of preventing alcohol use during pregnancy, and, if you teach NP students be sure they have the knowledge and skills to also be leaders and champions.

Let’s start by agreeing to set the record straight regarding the mixed messages women may receive from family, friends, and even other healthcare providers about whether it is safe to drink alcohol during pregnancy. There is no safe time, no safe amount, and no safe type of alcohol to drink during pregnancy.

Alcohol is a known teratogen that readily crosses the placenta. When a developing baby is exposed to alcohol it can lead to permanent conditions known as FASDs. A range of developmental, cognitive, and behavioral problems can occur, appear at any time during childhood, and last a lifetime. We don’t have a crystal ball to know who might be affected and how seriously. Genetics, environment, and other exposures may all contribute to outcomes. Every pregnancy is different so alcohol exposure can affect each developing baby differently even in the same woman.

The Facts

  • About 1 in 9 pregnant women reported drinking alcohol in the past 30 days and one third of pregnant women who reported consuming alcohol engaged in binge drinking.1
  • Drinking alcohol while pregnant can cause miscarriage, stillbirth, premature birth, and FASDs.
  • Alcohol-exposed pregnancies are a leading cause of preventable birth defects and neurodevelopmental abnormalities in the United States.
  • Based on National Institutes of Health-funded community studies, experts estimate that the full range of FASDs in the United States might number as high as 1 to 5 per 100 school children.2

There is no safe time to drink during pregnancy — Prenatal alcohol exposure at any time during pregnancy can cause developmental problems. Brain development occurs throughout gestation. Because alcohol exposure affects the developing baby through a variety of mechanisms and impacts different body systems, timing of the exposure can influence some of the potential effects. You can use a fetal development chart to facilitate discussion with your patients about developmental timing. The chart can help you to make the point that while it is best to stop drinking prior to becoming pregnant, it is never too late in pregnancy to stop drinking and lessen potential effects. The fetal development chart can also be used when you provide preconception counseling. Approximately half of pregnancies are unplanned, so women could potentially be drinking alcohol before they realize they are pregnant.

There is no safe amount of alcohol to drink during pregnancy – No amount of alcohol is currently deemed safe during pregnancy. This is true for most known teratogens. We don’t know a dose threshold for teratogenic effects. We do know that because alcohol readily crosses the placenta, a developing baby can be exposed to the same level of alcohol as the mother.

There is no safe type of alcohol to drink during pregnancy – all types of alcohol can be equally harmful to the developing fetus, including all wines and beer.

Are you ready to answer the call to action? Here are some useful resources.

The CDC and Collaborative for Alcohol-Free Pregnancy
Mother’s Womb: Baby’s First Environment Graphic

Fetal Development Chart 

Free online continuing education courses for healthcare providers on the prevention, identification, and management of FASDs

University of Pittsburgh School of Nursing
Fetal Alcohol Spectrum Disorders Toolkit for Nurse Champions

Optimizing Preconception Health: Preventing Unexpected Teratogen Exposure in Reproductive Age Women is a series of seven taped webinars on different aspects of this topic.

The National Organization on Fetal Alcohol Syndrome (NOFAS) provides fact sheets, videos, and other resources for professionals and individuals impacted by FASDs.


  1. Denny CH, Acero CS, Naimi Ts, Kim SY. Consumption of alcohol beverages and binge drinking among pregnant women aged 18-44 years – United States, 2015-2017. MMWR. 2019; 68:365-368.
  2. May PA, Chambers CD, Kalberg WO, et al. Prevalence of fetal alcohol spectrum disorders in 4 US communities. Journal of American Medical Association. 2018;319(5):474–482.