Comparing national vs. Ca LM neonatal mortality stats + Mother-baby risk status defined by Childbirth Connection

Background info to support re-adoption of the Criteria for Client Selection from our previous Standard of Care/current MBC Practice Guidelines for Ca LMs:

Recent and definitive info on national birth certificate reporting of NNM in the Linked Birth/Death Data set AND the NNM rate averaged for the last 4 years of LMAR data (over 10,000 births with NNM rate for Ca LMs of 1.3 per 1,000)

CDC’s National Vital Statistics Report provides statistics for live births in all 50 states and territories . This includes the total number of live births, and birth-outcomes from mothers and babies by birth order, age of parents, ethnicity, gestational age and birth weight of the baby, plus an exhausting list of miscellaneous and esoteric data sure to put an ordinary mortal to sleep.

Birth certificate data also reports the total number and rate of vaginal births, Cesarean deliveries, inductions, other medical and surgical procedures (except for episiotomies) and number and rate of maternal and neonatal morbidity in the top five categories for both.

In 2012, the total number of live birth in the US and territories was 3,952,841 (3.9 million). However, the full set of statistical data (2003 revision of the national birth registration form) with reliable breakdown of medical data only includes information from the 38 reporting states & DC. That data set if only 3,412,436.

Data below on NSVD, C-section, place-of-birth, and category of birth attendant reflect information from this 38 states, which includes California.

The number of spontaneous vaginal births in 20102 was 2,171,651 (2.1 million) and 1,296,070 Cesarean surgeries were performed (1.3 million). Forceps and vacuum extraction were used in 117,022 births .

When operative vaginal deliveries are combined with the number of Cesareans performed, the total number of surgical deliveries in this subset of only 38 states is over 1.4 million (1,413,092), which is more significantly more than third of all births in the US.

Even this high number does not include episiotomy, which is surgical procedure in which a pair of sterile scissors are used to cut the childbearing mother’s perineum (i.e. the delicate isthmus of skin, subcutaneous fat and deep muscle that includes all the external and internal tissues between the woman’s vagina and rectum).

While our national nativity statistics do not at present collect statistics for this surgical procedure, other source identify that approx. 35% of childbearing women have an episiotomy performed, often as a preamble to the use of forceps or vacuum extraction.

The National Vital statistics Record also records both place-of-birth and category of birth attendant.

The total # of OOH births in 2012 was 53,635, which included:
35,184 in parents’ homes,
15,577 in birth centers,
2,424 in “other”
450 doctors offices

OOH” place of birth stats also record by category of birth attendant:
Non-nurse midwife — 22,957
Nurse midwives (CNM) — 16,040
“Other” — 2,352
Medical Doctors —2,352

However the NVSR does NOT record fetal or neonatal deaths.

In order to get neonatal mortality statistics the CDC’s “Linked Birth/Infant death Data Sets” must be used.

The most recent publication (Dce 18, 2013) reporting national statistics for neonatal mortality is for 2010. It includes most of the same type of data as the birth certificate, in that numbers and rates of neonatal deaths are also calculated based on demographic categories for the parents (age and ethnicity, etc) and gestational ages and birth weights for babies that died.

But unfortunately, NNM data does NOT pair or calculate mortality relative to either the planned or actual ‘place-of-birth’. Neither does it give NNMR by category of birth attendants (MD, CNM, LM, other, etc). No neonatal mortality data that is specific to planned OOH births for professional nurse and direct-entry midwives is available via birth or death certificate data sets.

The closest comparison of outcomes between hospital-based obstetrics and professional midwives providing care in OOH settings are national neonatal mortality statistics for the categories of gestational age @ term (37.0 to 42+ wks) and birth weight (over 2,500 grams). Birth certificate data includes congenital anomalies.

Midwives providing community-based (OOH) childbirth services to essentially healthy women don’t attend any OOH labor until the mother has completed 37 wks of pregnancy. In addition they generally transfer any pregnancy woman who fetuses has signs or symptoms of severe growth restriction. This means the vast majority of mothers whose babies are delivered by Ca LMs would be 37+ weeks of gestation, have babies weighing at least 2,500 grams.  By averaging the outcomes of these two categories, we get data that allows comparison of outcomes btw professional community-based midwifery care and hospital-based obstetrical management.

Using the final data for 2010 from the ‘linked birth-death data set’, the overall number and percentage of babies born that year in these two vital categories — term gestational age over 37.0 to 42+ wks, and all babies born with a birth weight over 2,500 grams — could be determined.

The annual total of live birth in 2010 was 3,999,386. Of those,  3,515,317, occurred after the term of pregnancy (37 wks thru 42+wks), which represents 88% of all births that year.

Within that subset of term-born babies, there were 8002 neonatal deaths reported or a NNMR of 2.3 (1:439)

There were 3,671,997 babies born who weighed more than 2,500 grams at birth or approx 89% of total. Within that subset of normal birth weight babies, there were 7,821 neonatal deaths or 1:469 for a NNMR per 1,000 of 2.1.

When averaged, the NNMR is 2.2 per 1,000 in the US

Statistics from the LMAR 2010 to 2013

The total number of mothers who began labor at home with the intention of having a planned OOH birth were 10,668. 

All neonatal mortality (including congenital anomalies incompatible with like) were 21 (1:505 births or 2:1000).

Excluding fatal birth defects, there were 14 neonatal deaths reported (1:762 or 1.3 per 1000) 

Data published by Childbirth in its “What Every Pregnant Women Needs to Know About Cesarean Section” give the following statistical definitions of maternal-infant risk status:

Very high                    1 to 10 of every 10 mothers or babies
High                             1 to   9 of every 100
moderate                     1 to   9 of every 1,000
Low                              1 to   9 of every 10,000
very low                      1 to   9 of every 100,000 mothers or babies

This means the average NNM rate (excluding fatal congenital anomalies) for Ca LMs over the last 4 years (1.3 per 1,000) is “moderate” and in the same statistical category as the national nativity stats for pregnancy outcomes @ term (37+wks)

As reported in the Linked Birth/Death Data Set for 2010 (last year available), the average NNMR in the US is 2.2 per 1,000.

According to the definitions of risk identified above, the NMR rate for Ca LMs (at 1.3 peer 1,000) and the US rate @ 2.2 per 1,000 are both in the risk category judged to be “moderate”.

These statistics, which clearly establish the relative safety of professional care of LM in OOH setting as equivalently safe,  should be included as ‘written testimony’ when proposed regulations for Ca LMs are submitted for approval by the Office of Administrative Law (OAL).

Comparing morbidity and medical interventions

In addition to neonatal mortality, these is also a very substantial difference in the rate for the top five obstetrical interventions —

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