Update from the States: Utah | Midwives Alliance of North America

Update from the States: Utah

Update from the States: Utah

Understanding Utah's Out-of-Hospital Vital Statistics Report

Last week, the Utah Department of Health released a report based on a data review of planned out-of-hospital (OOH) births for the period between 2010 and 2012.

As outlined in the report, the out-of-hospital birth rate has doubled since 2007, but at 2.7%, remains a small fraction of the total number of births in Utah. Planned homebirths make up approximately 70% of the total number of OOH births, with the remainder occurring in birth centers around the state.The "average" mother choosing to birth at home or in a birth center is well-educated, older than the average mother choosing a hospital birth and more likely to have already had children.

Utah allows for the practice of midwifery with or without a license. Those midwives who choose to license must follow a nationally accepted course of study, pass a national midwifery certification exam, be certified in CPR and neonatal resuscitation as well as meet additional pharmacology requirements. An informed consent document, signed by the client and detailing the midwife's licensure status and potential risks is required for all licensed midwives.

Unlicensed midwives often follow an identical course of study as the licensed midwives, including passing the midwifery certification exam and becoming a certified professional midwife (CPM). Many unlicensed midwives are trained, educated and highly skilled. National practice guidelines include the use of informed consent documents, which should clearly state the training, level of experience and certifications/licenses of the midwife.

A finding of concern noted in the report was a neonatal mortality rate for out-of-hospital births that appears to be nearly double the rate for in-hospital births. While this finding deserves the attention of the maternity care community, it may be skewed by the relatively small numbers of home and birth center births and the even smaller number of adverse outcomes. Because this is a particularly small cohort, there are problems with extrapolation to the broader pool of all births. Nationally, much larger studies of planned, midwife attended OOH births with healthy low-risk women have shown the infant mortality rates to be comparable to hospital rates.Outlier data reports that are not consistent with the many other studies on homebirth indicate the need for further research.

Midwives welcome the use of reviewed data with an eye to quality assurance and practice assessment. We are interested in and supportive of a deeper dive into the data to ascertain whether or not a neonatal mortality rate of 2.3 per thousand live births is indicative of a potential problem related to site of birth, practice variations in risk assessment, or a result of an unusually small number of occurrences, thereby making the data unreliable. Reviewing Vital Statistics data rarely gives an accurate picture because of the limitations of the information collected on birth certificates. In this review for example there is no way to identify births of women with intent to deliver at home who ultimately delivered in the hospital. In other words, women who planned a homebirth and were transported to a hospital for delivery were included in hospital birth numbers. According to Dr. Melissa Cheney, PhD, Associate Professor at Oregon State University, "When we only track the actual place of birth and not the intended place of birth, we introduce error based on what we call misclassification bias. This is particularly concerning when we are dealing with rare events like death, even one or two misclassified events can result in inaccurate findings and misleading comparisons." She goes on to say, "I want to commend Utah for analyzing data on birth outcomes by delivery site and provider type. This is a very important part of maternity care safety surveillance, particularly as more and more women are choosing to give birth outside the hospital. I recommend that all states evaluate their current birth certificate relative to the state of Oregon's data collection tool. Simple changes have allowed us to more accurately track outcomes from planned home, hospital and birth center births. In addition, I would encourage the midwives of Utah to consider participation in the MANA Statistics Project. Use of a validated tool that controls for provider type and planning status can improve the quality of data we use to inform policy and practice."

In conclusion, while the presentation of the data has been somewhat sensationalized in the media, this report clearly demonstrates some of the many reasons more and more families are choosing out-of-hospital birth. Intervention rates are significantly lower, including inductions, C-Sections and epidurals. Families who want the considerable health benefits to mother and baby of physiologic birth, bonding and breastfeeding often seek midwifery care and home birth or birth center birth to achieve those goals. As more families learn about and choose out-of-hospital birth, the midwifery community continues to strive to make the experience as safe as possible.


About the author

Holly Richardson trained as an RN and LDEM (currently inactive) and oddly enough, is now a political junkie. She has served in the Utah House of Representatives and writes Holly on the Hill, one of the Utah's most popular political blogs. In her spare time, she consumes books voraciously, loves to garden and to sew and play with her 5 grandkids, 3 of whom she delivered.

Comments

As co-author of this report, I would like to point out that the chief aims of the study were to identify weaknesses in our vital records data collection and to make a description of the current state of OOH birth in this state. It was not designed to draw outcome conclusions from the data. At best it is only able to help us identify general trends that might be worth investigating more closely.

Results of this report have already instigated changes in data collected on birth and death/fetal death certificates, and representation of OOH midwives on our Perinatal Mortality Review Committee. It has also spurred several other research avenues and system improvement initiatives.

With Dr. Cheyney, I encourage all midwives to contribute their data though the MANA dataset and to do their best to ensure accuracy and completeness. Until there is adequate, good quality data, the debate about safety and quality of care in OOH birth will always devolve into ideological posturing.

While deficient data does not give us definitive answers to our questions, identification of trends or areas of recurring concern should behoove midwives to examine weaknesses in their own practices and look at ways to improve overall practice cultures in their communities. This is not meant to imply blame or point fingers at "bad" midwives, but is a function of continuous quality improvement and fundamental to evidence-based care which is a hallmark of midwifery care.

With Dr. Cheyney, I encourage all midwives to contribute their data though the MANA data set and to do their best to ensure accuracy and completeness. Until there is adequate, good quality data, the debate about safety and quality of care in OOH birth will always devolve into ideological posturing.

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