Seven.
That’s the number Rose Mary Ainsworth couldn’t stop thinking about.
In 2012, seven newborns experienced accidental falls while rooming in with their families during their birth hospitalization at Huntsville Hospital for Women & Children. That year, the hospital welcomed 4,971 babies into the world.
Today, it is Alabama’s busiest maternity hospital. Although the incidents were exceptionally rare, for the nurses who cared for those families, even one was too many.
After decades of caring for mothers and newborns, Ainsworth knew something wasn’t right. She found herself asking a simple question: What was different now than years ago?
There wasn’t a clear answer. Even more surprising, there wasn’t much research to guide them.
Then-Mother Baby Unit Director Cathy Mog asked Ainsworth, then the unit’s nurse educator, to investigate what was happening.
“We’ve got to do something about this,” Mog told her.
That conversation would change the course of Ainsworth’s career.
“I never would have dreamed I’d enjoy research and writing,” Ainsworth said. “Cathy really changed my life.”
Rather than accepting the falls as isolated incidents, Mog, who dedicated more than 40 years of service to improving maternity care at Women & Children, challenged Ainsworth to lead an effort to better understand why newborn falls were occurring and how they could be prevented.
Ainsworth assembled a committee of 14 Mother Baby nurses with diverse clinical backgrounds. Together, they reviewed each newborn fall, interviewed families, searched the available medical literature and contacted other hospitals to learn how they were approaching newborn fall prevention.
What they discovered was surprising.
Only two published articles on newborn falls existed at the time.
Rather than waiting for someone else to solve the problem, the committee developed its own comprehensive newborn fall prevention initiative.
Over seven months, the team created a newborn falls policy and procedure, staff education, bedside safety tools, updated crib cards, room signage and one of the nation’s first newborn fall prevention assessment scales. Working with the hospital’s marketing department, the committee also developed educational posters for patient rooms and staff areas to reinforce newborn fall prevention and safe sleep practices.
Every employee on the Mother Baby Unit completed education before the initiative launched in July 2012.
The changes also transformed bedside care. Nurses implemented quiet times during the day and night to encourage family rest, strengthened parent education and worked with the hospital’s safety committee to allow bed rails to remain raised while mothers fed newborns overnight. The change provided an additional layer of protection during one of the highest-risk times.
“Preventing newborn falls became part of our DNA,” Ainsworth said.
The results were encouraging.
Following implementation of the initiative, the incidence of newborn falls decreased and the prevention strategies became a standard part of care on the Mother Baby Unit.
The team’s work quickly began attracting national attention.
In 2013, Women & Children’s newborn fall prevention initiative earned first place for an evidence-based practice poster at the national Association of Women’s Health, Obstetric and Neonatal Nurses convention. The following year, the team again earned first-place recognition after presenting the program as an educational session.
In 2016, Ainsworth and her colleagues published A Comprehensive Initiative to Prevent Falls Among Newborns in Nursing for Women’s Health, sharing the prevention program developed at Women & Children and the improvements seen after implementation.
As awareness of the program spread, nurses from hospitals across the country began contacting Ainsworth for guidance. Many hospitals adopted the newborn fall prevention assessment scale developed by the Women & Children team.
The initiative also gained recognition among national leaders in patient safety. Ainsworth and Mog were invited to participate in a national newborn falls summit alongside experts from organizations including The Joint Commission, Cleveland Clinic and Nationwide Children’s Hospital to help advance newborn fall prevention strategies.
As additional research on newborn falls emerged over the following years, Ainsworth noticed the findings often conflicted.
“We realized the research didn’t always agree,” she said. “If we wanted to improve the assessment tool, we needed better data.”
Working alongside Mother Baby Charge Nurse Maria Caceres, Clinical Education Specialist Bonnie Mullen and retired University of Alabama in Huntsville nursing professor Dr. Ellise Adams, Ainsworth launched a new multi-hospital research effort.
The team contacted hospitals that had previously reached out to Women & Children about newborn fall prevention. Fifteen hospitals ultimately contributed data from 88 newborn falls occurring between 2016 and 2025, creating one of the largest studies examining newborn falls during the birth hospitalization.
By bringing together experiences from hospitals across the country, the research gave the team a broader understanding of newborn fall risk factors than any single hospital could provide. Those findings informed an updated newborn fall prevention assessment scale, and the team is now working to validate it through a third publication.
The culmination of more than 14 years of quality improvement, collaboration and research was published in the July/August 2026 issue of MCN: The American Journal of Maternal/Child Nursing, one of the nation’s leading peer-reviewed journals focused on maternal-child nursing.
The study identified 11 factors associated with increased newborn fall risk, including overnight hours, the second and third nights after birth, cesarean delivery, maternal blood loss or anemia, prescribed opioid use within four hours of a fall and significant postpartum fatigue. The findings provide evidence-based guidance that hospitals can use to better identify higher-risk situations and strengthen newborn fall prevention programs.
Rather than placing blame on parents, the research recognizes that childbirth is physically demanding and that hospitals play an important role in identifying families who may need additional support. By recognizing risk factors early, maternity teams can implement evidence-based interventions that help prevent newborn falls before they occur.
Today, hospitals across the United States continue using tools developed by the Huntsville Hospital for Women & Children team, and the research continues.
Ainsworth, who retired in April after more than four decades in nursing, said she was confident leaving the work in the hands of Maria Caceres and Bonnie Mullen, who are continuing the research and are currently working on a third publication to validate an inpatient newborn fall prevention assessment scale.
For Ainsworth, the publications and national recognition have never been the goal.
The goal has always been safer care for mothers and babies.
“I didn’t do this by myself,” she said. “It took a team of nurses who cared deeply about our patients and wanted to make things better.”
Looking back, she hopes the work demonstrates what can happen when frontline nurses are empowered to ask questions and pursue solutions.
“Anybody who cares about patients could do this work,” Ainsworth said. “You see a problem, you ask questions and you work together to find a better way.”