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Gateway to the Future: Improving the National Vital Statistics System

Cindy Hooley Phone (802) 651-1636. The Vermont Department of Health. Are Home Births Attended by Midwives at Greater Risk of Morbidity, Mortality, and Other Adverse Outcomes?. Gateway to the Future: Improving the National Vital Statistics System

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Gateway to the Future: Improving the National Vital Statistics System

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  1. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health Are Home Births Attended by Midwives at Greater Risk of Morbidity, Mortality, and Other Adverse Outcomes? Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010

  2. Cindy Hooley Phone (802) 651-1636 Home Births: National Trends The Vermont Department of Health From 1990 to 2004, the rate of home births in the U.S. declined from 0.69 to 0.57 percent of births. After many years of decline, there are indications of a possible reversal, with an increase to 0.59 percent of births in 2005 and 2006. The percentage of home births varies widely by state: Vermont 2.37% Montana 2.28% United States 0.59% Nebraska 0.19% Louisiana 0.18% Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 2

  3. Cindy Hooley Phone (802) 651-1636 Percentage of Out-of-Hospital Births, by Place of Delivery: United States, 1990 and 2006 The Vermont Department of Health 1990 2006 Source: National Vital Statistics Report, Vol 58, Number 11, “Trends and Characteristics of Home and Other Out-of-Hospital Births in the United States,” 1990-2006 Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 3

  4. Cindy Hooley Phone (802) 651-1636 Home Births: National Discussion The Vermont Department of Health Home births have been a topic of discussion among the medical community in recent years. The American College of Obstetricians and Gynecologists' (ACOG) position statement contends that birth should only take place in the hospital setting. ACOG’s statement was supported by a resolution passed at the 2008 American Medical Association meeting. The American College of Nurse Midwives, and the American Public Health Association, have policy statements supporting the practice of out-of-hospital birth in select populations of women. There is ongoing debate about the ACOG and AMA position, and the evidence that was used to raise concerns of safety in a home birth setting. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 4

  5. Cindy Hooley Phone (802) 651-1636 Home Births: Vermont Midwife Requirements The Vermont Department of Health Licensure as a midwife in Vermont requires: • Obtained certification as a certified professional midwife (CPM) from the North American Registry of Midwives (NARM); • Earned a high school degree or its equivalent; • Agreed to practice according to the scope and standards of practice set forth in the Vermont Administrative Rules for Midwives; • Receive 20 hours of continuing education during the two-year license renewal period. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 5

  6. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health Midwives may not assume or continue to take responsibility for a client if one of 29 medical disorders or situations pre-exist or become apparent. Examples: diabetes mellitus; chronic pulmonary disease; renal disease; premature labor (gestation less than 36 weeks); alcohol use daily or binge behavior into second trimester; etc. Midwives must consult with a licensed M.D. or D.O. when one of 21 medical disorders or situations pre-exist or become apparent. Examples: “significant” mental disease; asthma; previous uterine surgery; postmaturity (gestational age more than 42 weeks); continued daily use of tobacco into second trimester; etc. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 6

  7. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health Midwives must transfer the client to a hospital setting if one of 14 conditions becomes apparent during labor or birth. If time does allow for transfer, the midwife must consult with a licensed M.D. or D.O. to determine whether or when a transfer would be advisable. Examples: non-reassuring fetal heart rate; Apgar of less than seven at ten minutes; signs of fetal or maternal infection; obvious congenital anomalies; etc. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 7

  8. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health The Public Health Statistics Section has received occasional requests from members of the public, medical community, and researchers to examine the planned home birth data. In 2006, members of the Vermont medical community asked the Health Commissioner to assess whether planned home births attended by a midwife encountered more or different adverse outcomes than a facility birth attended by a physician. The request was based on an assumption that midwives were not consistently transferring responsibility of the patient to a physician when one of the 29 conditions / situations required such action, resulting in more adverse outcomes. Vital Records and the Statistics staff conducted analyses in 2006 and 2010, comparing planned home births attended by a midwife to births that occurred at a hospital facility and attended by a physician. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 8

  9. Cindy Hooley Phone (802) 651-1636 Comparison Results The Vermont Department of Health Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 9

  10. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health Question: Are midwives relinquishing oversight of births to a physician as required by the Administrative Rules? Births that may have required Relinquishment, but were not transferred to physician Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 10

  11. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health Question: Are there more occurrences of congenital anomalies for those planned home births overseen by a midwife?* *This question arose from the medical community’s concern that midwives were not discussing or offering genetic counseling. Yellow Shaded Boxes: Decrease in reported events appears to be the caused by our implementation of the revised U.S. Standard Birth Certificate in 2005. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 11

  12. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health Question: Are there more occurrences of abnormal conditions for those planned home births overseen by a midwife? Are they being transferred to a hospital? Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 12

  13. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health Question: Is there a difference in Gestational Age by the place of birth (midwife-attended Home Birth vs. physician at Hospital)? Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 13

  14. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health Question: Is there a difference for postpartum hospitalizations and ED visits based on planned home birth vs. hospital birth?* Not statistically different Not statistically different Statistically different Statistically different *The analysis was conducted on Medicaid clients using the claims data. ED and hospitalizations were based on visits in the first month of the infant’s life. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 14

  15. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health Question: Is there a difference in prenatal care and behavioral risks based on planned home birth and hospital birth?* *Data source is the Vermont Pregnancy Risk Assessment Monitoring System (PRAMS). The data is self-reported by the mother post delivery. **Home births based on small numbers (less than 60 survey responses) and subject to large confidence intervals. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 15

  16. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health Question: Is there a difference in medical complications of the pregnancy for planned home birth and hospital birth?* *Data source is the Vermont Pregnancy Risk Assessment Monitoring System (PRAMS). The data is self-reported by the mother post delivery. **Home births based on small numbers (less than 60 survey responses) and subject to large confidence intervals. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 16

  17. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health Question: Any differences in the mother’s decision-making based on planned home birth and hospital birth?* Newborn Metabolic Screening - % of Mothers that Refused Screening *Data source is the Vermont Newborn Metabolic Screening Program. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 17

  18. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health Conclusions There is no evidence that a planned home birth attended by a midwife has a greater likelihood for adverse outcomes than a hospital birth attended by a physician. However, it is important to remember that these home births are those without significant risk factors or the potential for complications. The Administrative Rules require that those births be transferred to a physician and/or hospital. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 18

  19. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health Unexpected Positive Outcomes: • Among the Medicaid clients, the home births were less likely to be hospitalized in the 30 days after the birth. • Planned home births had a significantly lower incidence of some medical complications of pregnancy (e.g., nausea). Note: These positive outcomes may be due to the requirements for which births a midwife must transfer responsibility to a physician. • More likely to receive counseling about breastfeeding and a higher quit rate for smoking during the pregnancy. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 19

  20. Cindy Hooley Phone (802) 651-1636 The Vermont Department of Health Areas for Further Exploration: • Possible lower percentage of First Trimester Prenatal Care? • Possible lower quit rate for drinking during pregnancy? • Lower usage of certain health screening services, such as Newborn Metabolic Screening; • Midwife might not be relinquishing oversight of the birth to a physician in a small number of cases (1%), per the Administrative Rules. • However, it may be that the midwife consulted a physician and was allowed to maintain responsibility for the birth. Unknown without conducting a direct interview with all involved parties. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 20

  21. Cindy Hooley Phone (802) 651-1636 Vital Records in Vermont: Contacts The Vermont Department of Health Cindy Hooley Vital Statistics Information Manager cindy.hooley@ahs.state.vt.us Phone: (802) 651-1636 Richard McCoy Public Health Statistics Chief richard.mccoy@ahs.state.vt.us Phone: (802) 651-1862 Special thanks to analysts: Moshe Braner, Jason Roberts, Mike Nyland-Funke, and Meg Baldor for their assistance with the analyses! Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 21

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