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As a graduate student years ago, I was strugglingto understand the problem of substance abuse inpregnancy when I encountered Butterfield’s (1990)article, “Thinking Upstream: Nurturing a Conceptu-al Understanding of the Societal Context of HealthBehavior.” To understand the roots of unhealthylifestyles from which so many health crises arise,Butterfield advised nurses to look back “upstream”to harmful influences that had been “dumped” intoour clients’ geographic environments, cultural com-munities, and sociopolitical contexts.

A vivid image came to me of a flowing river,afloat with pregnant women. Many pregnant drugusers had suffered abuse and neglect upstream, intheir families and communities of origin. They strug-gled with subsequent educational deficits and men-tal health problems, with few resources or role mod-els. Despite their deep desire to be good mothers,they had been given few tools for change. Thinkingupstream helped me see why nurses’ well-meaningpatient education on the harms of substances waswoefully inadequate.

Thinking upstream is even more important today.The Clinical Issues series in this issue will make clearthat despite advances in high-tech care, includingsophisticated screening tests and pharmacologictocolysis, national prematurity rates are rising.Although many preterm births cannot be predicted,both AWHONN and the March of Dimes, partnersin a campaign to reduce prematurity (Association ofWomen’s Health, Obstetric and Neonatal Nurses,2003), have directed health leaders to address therisks we know. Thinking upstream means becomingaware of community-level risks that shape the livesof the women in our care.

Do you know the preterm birth rates for yourcounty and state, or the prevalence of populationrisk factors? Using Peristats, a March of Dimes(2003) online resource for state and local data onperinatal risks, I discovered that in my state ofMassachusetts, our prematurity rate in 2000 was10.1%, up dramatically since 1990, and well abovethe national Healthy People 2010 objective of 7.6%.In North Carolina, the home state of Mary Lou

Moore, guest editor of this issue’s Clinical Issuesseries on Prematurity, the preterm birth rate in 2000was 13%, lamentably high but, unlike Massachu-setts, fairly stable over 10 years.

What accounts for the difference in the twostates? Peristats revealed that, despite my stereo-types of Boston as a medical mecca and North Car-olina as rural and underserved, the two states’ sta-tistics for poverty, access to care, and adequacy ofprenatal care were similar. The differences were else-where: North Carolina’s rate of sexually transmitteddiseases was 2 to 4 times higher than in Massachu-setts, but Massachusetts had a dramatic increase inmultiple births to older mothers.

How can nurses address the root causes of pre-maturity? These figures show that Mary Lou Mooreand I must tackle different problems. In states likemine, where funding for infertility treatment is man-dated, nurses must help mature women to balancecareers and timing of motherhood, and advocate forrestrained use of technology. In states like NorthCarolina, nurses must reach out to educate youngwomen about sexual risks, screen systematically forsexually transmitted diseases, and advocate forbroad screening, treatment, and follow-up.Although these are overly simple solutions to anextremely complex problem, knowing our commu-nities’ health status is the first step to reduce prema-turity risk.

Thinking upstream, despite the allure of highsalaries and the real need for nurses in acute care,some of us must commit to re-energizing publichealth nursing, to serve in homes, streets, and work-places where health and illness begin. Facing shrink-ing state budgets, we must speak out to protect pub-lic health nursing programs. In our one-on-one care,as Tiedje advises us in this issue, nurses must assessnot only women’s symptoms but also their homesand histories. Where have they come from, and whatare their burdens and concerns? If health beginsupstream, health problems such as prematurity canonly be solved using an ecological frame of mind.Our interventions should target both immediateneeds and upstream causes, including social, eco-nomic, and environmental risks and stress.

September/October 2003 JOGNN 577

EDITORIAL

“Thinking Upstream” to Confront Prematurity

Learn more about stressors, health behaviors, and pre-maturity in Clinical Issues this month. Note that you canearn Continuing Education credit for reading the six arti-cles and completing a brief posttest. Look for ContinuingEducation credit opportunities for selected Clinical Issuesseries in the months to come.

Margaret H. KearneyAssociate Editor

REFERENCES

Association of Women’s Health, Obstetric and Neonatal Nurs-es. (2003). March of Dimes and AWHONN PrematurityCampaign. Retrieved May 26, 2003, from http://www.awhonn.org/awhonn/?pg=873-9460

Butterfield, P. (1990). Thinking upstream: Nurturing a concep-tual understanding of the societal context of health behav-ior. Advances in Nursing Science, 12(2), 1-8.

March of Dimes. (2003). Peristats: An interactive perinatal dataresource. Retrieved May 26, 2003, from http://peristats.modimes.org

578 JOGNN Volume 32, Number 5

Vicki Akin, RN, MSNErin Anderson, RN, MSNLinda Bell, RN, PhDLynn Clark Callister, RN, PhDElizabeth Carlson, PhD, RN, WHNPAnita Catlin, DNSc, FNPSandra K. Cesario, RNC, PhDAndrea Christian, RN, MS, CNSElizabeth G. Damato, RNC, PhDAnita DeWeese, RNC, MSNBarbara Leary Dion, RNC, ICCE, MA, MSNEileen R. Fowles, RNC, PhDPamela Dee Hill, RN, CBE, PhD, FAANDiane Holditch-Davis, RN, PhD, FAANLori Jackson, RNC, NNPSheryd J. Jackson, RNC, MS, WHNPLinda J. Juretschke, RNC, PhD, NNPColleen Keenan, WHNP, PhD, FNPVirginia L. Kinnick, RN, CNM, EdDGail Lemaire, PhD, APRN, BCLynne P. Lewallen, RN, PhDLouise K. Martell, RN, MN, PhD Patricia R. McCartney, RNC, PhD Rebecca S. Miltner, RNC, MSKristen Montgomery, RN, PhDAnne A. Moore, RNC, MSN

Dianne Morrison-Beedy, RNC, WHNP, PhDMary R. Nichols, RN, CS, FNP, PhDSusan A. Orshan, RNC, PhDKathie Records, PhD, RNMichelle Renaud, PhD, RNPatsy Ruchala, DNSc, RNCyndi Roller, WHNP, CNM, PhDRebecca B. Saunders, RNC, PhDJan Sherman, RN, NNP, PhDMaureen Shogan, RNC, MNLinda Snell, DNSMary Ann Stark, RNC, PhDDeborah Steward, RN, PhDLynn Stover, RN, BC, DSNMarilyn Stringer, PhD, CRNP, RDMSPatricia Dunphy Suplee, CS, RNC, PhDRosemary Theroux, RNC, PhDNancy Townsend, RN, MSNLeona Vande Vusse, CNM, MSNTerrie Watkins, RNC, CNM, MSNKathryn Wekselman, RN, PhDCandy Wilson, RNC, MSNJeanne M. Wilton, RNC, MS, IBCLC, WHNPRuth Wittman-Price, CNS, MSN, RNMargaret R. Wood, RN, PhDRuth York, RN, PhD, FAAN

JOGNN Reviewer Panel: 2003