1. Gathering data on planned place of birth
Oregon’s HB 2380
Gathering data on planned place of birth
Sarah Hargand, MPH
Research Analyst
Center for Health Statistics
Oregon Health Authority

2. HB 2380
The 2011 Oregon legislature passed House Bill that required the Center for Health Statistics to gather new information on planned place of birth for both live births and fetal deaths and report on outcomes.
Two new questions are added to the birth and fetal death certificates.
HB2380 was passed in July of 2011

3. Overview Background 2011 Legislative Session
Out-of-Hospital Births in Oregon
Midwives
Implementation
Training
Quality Assurance
Analysis
Preliminary Report
Special Perinatal Case Fatality Report

4. Public hearings and work sessions
2011 Legislative Session
HB 2380 is introduced
Public hearings and work sessions
HB 2380 is amended.
Consensus was complicated by several high profile cases of infant death involving unlicensed midwives and strong support from hospitals for additional oversight of midwives coupled with very passionate involvement of both midwives and birthing mothers.

5. HB2380
“The Center for Health Statistics shall collect and report data on birth and fetal death outcomes occurring in this state, including intrapartum and neonatal transfers to hospital care from another birthing facility, hospital or other location. The center shall report the data by attendant type. The report shall distinguish outcomes between licensed direct entry midwives and direct entry midwives who are not licensed under ORS to ”
The Center for Health Statistics was chosen as the neutral party and tasked with collecting and reporting on outcomes by attendant type. A workgroup decided on the questions and chose to ONLY collect title of attendant and not the actual attendant name.

6. Out-of-Hospital Births
Oregon generally has a higher percentage of out-of-hospital births than the U.S. (3.4 versus 1.2 in 2010).
Oregon’s rate of OOH births was 3.7 in 2011.
U.S. rate not available

7. Oregon Births Occurring Out-of-Hospital, 2011
In 2011 there were 1680 births occurring out-of-hospital or 3.7% of the total births.
Of these, the majority (58.1%) were planned to occur in the mother’s residence. 35.8% occurred at a freestanding birthing center.
Free-standing birthing centers are licensed by the Health Care Regulation and Quality Improvement, Oregon Public Health Division (13).
Oregon has one of the highest rates of planned homebirth

8. Midwives
In the State of Oregon, a midwife does not need a license to practice midwifery.
The Oregon Center for Health Statistics collects data on three different types of midwives.
LDMs are direct entry midwives who have volunteered for state licensure through the Oregon Health Licensing Agency. They must meet qualifications and adhere to regulations set by the State of Oregon.
Unlicensed midwives are not licensed in Oregon, but are registered with the Center for Health Statistics to certify births.
Attendant Type
Percent of Births, 2011
Hospital Births
Planned OOH Births
Certified Nurse Midwives (CNM)
17%
16%
Licensed Direct Entry Midwives (LDM) 0%
62%
Unlicensed Midwives 7%

9. Implementation
Two new questions are added to the birth and fetal death certificates effective January 1, 2012.
Did mother go into labor planning to deliver at home or at a freestanding birthing center?
If yes, the planned primary attendant type at onset of labor was:
Every mother who delivers in the hospital must be asked if she planned to deliver at a private home or a
freestanding birthing center at the time she went into labor.

10. Implementation July 2011: HB2380 is passed
Aug. 2011: Work order to vendor
Sept. 2011: Contact stakeholders
Oct. 2011: Newsletter to birth clerks
Nov. 2011: Birth & Fetal worksheets updated, webinar created
Dec. 2011: Database structure updated
Jan. 2012: Questions go live
Tasks included updating birth/fetal death certificates, discussions with vendors, writing newsletter articles,
developing demos, website content, updating database, and report planning. At every step there was a considerable amount of time testing.

11. Implementation Total Cost: $38,757.25 Total Staff Time: $26,257.25
Hours: 682.5
Vendor Costs: $12,500.00
Hours: 85

12. Quality Assurance Quality assurance started in February and included:
Response rate
Verification of planned out-of-hospital birth
3) Verification of attendant type
This required collaboration between the statistics unit, the registration unit, and the birth clerks at hospitals.

13. Jan. 1, 2012- Sept. 30, 2012 Oregon Occurrence Births
Preliminary Report
Jan. 1, Sept. 30, 2012 Oregon Occurrence Births
Place of Birth
Total Term Births
Neonatal Deaths
State Total
31,883 29
Hospital Births
30,330 24
Planned Out-of-Hospital Births
1,493 5
Born in Hospital
320 4
Other 60
The second part of HB2380 required the Center for Health Statistics to report on the outcomes of planned out-of-hospital births by planned attendant type. A preliminary report was released in November 2012 by the State Public Health Director.
The small number of deaths among births planned out of hospital made it impossible to separately
distinguish the impact of licensure status, attendant type and place of delivery on risk of perinatal death.
However, these data do suggest at least two areas of focus for public health efforts:
Which women are choosing to have OOH births.
What happened to those infants who died.

14. Maternal Characteristics, 2012 Births
Special Report: Maternal Characteristics
Maternal Characteristics, 2012 Births
Hospital
Planned OOH
Mother's Age 30+
43%
57%
White, non-Hispanic
68%
87%
Married
64%
83%
College Educated
29%
46%
Self-pay 1%
28%
Study involved the State Epidemiologist, and CDC EIS Officer, Statistics unit staff, and a perinatal nurse consultant.

15. Medical & Health Characteristics, 2012 Births
Special Report: Medical & Health Characteristics
Medical & Health Characteristics, 2012 Births
Hospital
Planned OOH
No Prenatal Care
0.4% 3%
First Trimester care
77%
64%
Overweight/Obese
49%
32%
Tobacco
11% 2%

16. Special Perinatal Fatality Case Review
For 2012, the Oregon Public Health Division conducted a special study involving a perinatal fatality case review of term births intended to occur out-of-hospital.
1,995/41,979 (4.8%) planned an out-of-hospital birth
381 of 1,995 (19.1%) planned out-of-hospital births ultimately delivered in-hospital

17. Special Perinatal Fatality Case Review
9 (9.7%) term fetal and neonatal deaths occurred among planned out-of-hospital births
7 of 9 transferred to the hospital during labor
These 9 deaths underwent a fetal and neonatal mortality case review per published national guidelines
63 term fetal deaths occurred in Oregon during 2012; 4 (6.3%) of these occurred among planned
out-of-hospital births. 30 term neonatal deaths occurred in Oregon during 2012; 5 (17%) of these occurred among
planned out-of-hospital births.  

18. Special Perinatal Fatality Case Review
6 of 9 pregnancies did not meet published low-risk criteria for out-of-hospital birth:
More than 41 weeks gestation (4);
Twin gestation (2);
Untreated Group B streptococcus vaginal colonization (2);
Morbid obesity (>40 BMI) (1);
7 of 9 transferred to the hospital during labor: Indications for transfer to a hospital from home or birthing center included
(multiple causes may apply): loss of fetal heart tones (3), prolonged labor (2), decreased fetal movement (2), malpresentation (2),
and increased maternal blood pressure and trace urine protein (1).
One mother initially declined transfer during labor despite recommendation by birth attendant.
The term perinatal death rate in planned out-of-hospital births (4.0/1,000 pregnancies) was twice that of in-hospital births (2.1/1,000). Includes fetal and neonatal deaths ≥37 weeks estimated gestational age through first 6 days of life.

19. What’s Next?

20. Acknowledgments and Contact
Genevieve Buser, MD, MSHP
EIS Fellow, Oregon Public Health Division
Anna Stiefvater, RN, MPH
Perinatal Nurse Consultant, Maternal and Child Health
Katrina Hedberg, MD, MPH
State Epidemiologist and Chief Science Officer
Contact:
Sarah Hargand, MPH