Director’s Office

Report and Recommendations of the Direct-Entry Midwifery Data Reporting Task Force

Pursuant to §12-37-105.3, C.R.S. January 31, 2017

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Director’s Office

January 31, 2017 House Health, Insurance and Environment Committee

Senate Health and Human Services Committee

House Public Health Care and Human Services Committee Dear Committee Members, I am pleased to present the Report and Recommendations of the Direct-Entry Midwifery Task Force, pursuant to §12-37-105.3, C.R.S. After reviewing the issues presented in the statute, the Task Force developed recommendations that address the current problems associated with the requirement for direct-entry midwives to provide certain data to the Division of Professions and Occupations, part of the Department of Regulatory Agencies. The recommendations presented in this report reduce the regulatory burden on direct-entry midwives, but allow the Colorado Department of Public Health and Environment to continue collecting vital statistics that help monitor the public’s health. The Division appreciates having the opportunity to facilitate the work of the Task Force. Please let me know if you need additional information or have questions. Thank you for your consideration of these recommendations. Sincerely,

Ronne Hines Director Division of Professions and Occupations

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Department of Regulatory Agencies

Creation and Charge of the Direct-Entry Midwife Data Reporting Task Force On June 10, 2016, Governor John Hickenlooper signed House Bill 16-1360 Concerning the Continuation of the Regulation of Direct-Entry Midwives, which continued the Department of Regulatory Agencies’ (DORA) regulation of direct-entry midwives and gave DORA the authority to implement the recommendations from the 2015 Sunset Review: Direct-Entry Midwives. The legislation also gave the Director of DORA’s Division of Professions and Occupations (DPO) the authority to convene a Task Force to review and make recommendations on the data reporting requirements for directentry midwives set forth in §12-37-105(12), C.R.S. The new law, §12-37-105.3, C.R.S., gave the Task Force the authority to: ● Determine whether the information required to be reported under section §1237-105(12), C.R.S., should be modified; ● Identify ways to enhance the quality and usefulness of the data collected; ● Consider whether direct-entry midwives should report the data to different or additional agencies; ● Consider whether the director should use the data when determining whether to renew an applicant's registration; and ● Develop legislative and regulatory recommendations as necessary to implement the task force's findings regarding data collection and use. The new law also required the Director of the Division of Professions and Occupations to report the Task Force’s findings and recommendations to the House Health, Insurance, and Environment Committee, the House Public Health Care and Human Services Committee, and the Senate Health and Human Services Committee by January 31, 2017. Working Group Members In October 2016, Ronne Hines, Director of the DPO, appointed the following individuals to the House Bill 16-1360 Direct Entry Midwife Data Reporting Task Force: Kirk Bohl, Colorado Department of Public Health and Environment Courtney Everson, PhD - Midwives College of Utah Steven Holt, MD - obstetrician representative Jan Lapetino, RM, CPM - direct-entry midwife profession representative Joseph Marceny, MD - pediatrician representative (unable to attend) Margaret Mohan, RN - Colorado Department of Public Health and Environment

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Heather Pollock-Green, RM - direct-entry midwife profession representative (unable to attend) Lauren Smith-Kuckkhan - community/public consumer representative Sarah Stone, CNM - certified nurse midwife representative Suzanne Tully, RM, CPM - direct-entry midwife profession representative Meetings and Discussion The Task Force met on December 16, 2016 at the DORA office at 1560 Broadway, Denver, Colorado. History and Questions for Discussion The current reporting requirement set forth in §12-37-105(12), C.R.S., was established in 1992 and states: At the time of renewal of a registration, each registrant shall submit the following data in the form and manner required by the director: (a) The number of women to whom care was provided since the previous registration; (b) The number of deliveries performed; (c) The Apgar scores of delivered infants, in groupings established by the director; (d) The number of prenatal transfers; (e) The number of transfers during labor, delivery, and immediately following birth; (f) Any perinatal deaths, including the cause of death and a description of the circumstances; and (g) Other morbidity statistics as required by the director.

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In order to evaluate the data reporting requirement, the Task Force addressed four specific questions derived from the tasks identified by HB16-1360. 1. 2. 3. 4.

Should current data reporting requirements be modified? How can the quality and usefulness of the data be enhanced? Should the data be reported to a different or additional agency? Should the Division Director use the data when determining an applicant’s registration renewal?

1. Should current data reporting requirements be modified? The Task Force determined there is a need to modify the current data reporting requirement based on the following findings: ● Most of the data collected by DPO duplicates data already collected by the Colorado Department of Public Health and Environment (CDPHE), and should continue to be collected exclusively by CDPHE. ● Two of the data points ((a) and (d)), are purely statistical and do not add value to consumer protection or the consumer’s decision-making process. ● Data collected by the Director as required by statute may be duplicative or unclear. In addition, it is noteworthy the Director is only required to collect the data. ● It would be useful if the data collection would differentiate between rural and urban-based direct-entry midwives who have different levels of resources and supporting services. ● Given much of this data is also reported to CDPHE, the data collection through DORA creates an unnecessary regulatory burden on direct-entry midwives. ● Direct-entry midwives are the only profession reporting this type of data to DPO. Given that other providers licensed by DPO do not report similar data, no comparisons can be made with other type of providers to help consumers make informed healthcare choices. 2. How can the quality and usefulness of the data be enhanced? The Task Force considered the question of how the quality and usefulness of the data could be enhanced, and determined that the data currently collected by CDPHE is useful to the consumer in making informed decisions. Much of the data collected by DORA and CDPHE is the same. The Task Force recommended

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that CDPHE continue to collect the data and that data collection by DORA be discontinued. Specifically, the Task Force believes the data collected could be enhanced to improve the quality a.nd usefulness of the data for consumers by collecting such data through CDPHE. The recommendation entails the discontinuation of data related to “the number of women to whom care was provided since the previous registration” and “the number of prenatal transfers.” The Task Force recommends however that CDPHE consider how to appropriately collect and interpret data concerning “The number of transfers during labor, delivery, and immediately following birth”. Details concerning the Task Force’s recommendation follow. 1. Data is useful for consumer decision-making: Some consumers may want to compare data on hospital births, birthing center births and home-births in order to inform their healthcare choices. However, DORA only collects information from direct-entry midwives and, therefore, does not have the statutory authority to collect the data necessary to assist the consumer in this regard. Obstetricians, certified nurse midwives and direct-entry midwives all currently report data to CDPHE following a birth as part of the birth registration process outlined in § 25-2-112, C.R.S. 2. Data should be collected in a timely and consistent manner. Currently, direct-entry midwives must collect and hold data until the renewal period. This decreases the integrity and accuracy of the data which is not cleaned or validated after submission. In turn, data collected by CDPHE is timely, occurring after each birth as noted above. Additionally, under the current data collection process, direct-entry midwives may interpret questions differently, which can skew any effort to interpret aggregated survey results, and make the data inaccurate. Guidance should be considered to help standardize data collection and interpretation. 3. Clarity is needed for prenatal transfers and transfers during labor, delivery, and immediately following birth. It is important to note the Task Force focused much of its discussion on the current requirement to report the following: -

Number of prenatal transfers; Number of transfers during labor, delivery, and immediately following birth.

The Task Force determined that DORA’s collection of the transfer data creates a fragmented process for public health data. While the Task Force recommends housing this data collection, analysis and reporting with CDPHE it is important to note that CDPHE does not collect information about how, why, and when a direct-entry midwife transfers a patient to an appropriate

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healthcare facility. Some Task Force members stated the transfer data is important. As mentioned above, some Task Force members affirmed that transfers reflect a positive, important decision that is made in the best interest of the patient. Others agreed that transfer data could be useful, but expressed concern that it also can be misinterpreted and used in an attempt to show midwives are not competent and need assistance more than consumers may realize. Therefore, the Task Force came to the consensus recommendation that the state should continue to explore how to collect transfer data in a way that is useful to public health surveillance and mitigates the data that cannot be interpreted. 4. Should the data be reported to a different or additional agency? The Task Force considered this question in light of data collection requirements in § 25-2-112, C.R.S., because CDPHE collects much of the same data related to vital statistics. CDPHE does this in a more timely manner and from multiple practitioners (as described above) making that department ideally equipped to collect and interpret data concerning direct-entry midwives and the births with which they are associated. Specifically, the current data collection process at CDPHE addresses many of the Task Force’s concerns and ideas about the quality and usefulness of the data as described above and streamlines data collection to ensure it is neither duplicative nor unjustly burdensome. Accordingly, the Task Force recommends that data collection for direct-entry midwives be housed solely in CDPHE. 5. Should the Division Director use the data when determining an applicant’s registration renewal? The Task Force discussed if and how the data should be used when determining an applicant’s registration renewal. The Task Force recommends that the Director require data reporting to CDPHE, and that applicants (new, renewal and reinstatement) attest to such reporting as part of the application process by attestation given the CDPHE is already required of direct-entry midwives under Colorado law. The applicant does not need to provide duplicative data to DPO. Recommendations The Task Force submits the following recommendations for consideration: 1.

The current data reporting requirement set forth at §12-37-105(12), C.R.S. should be repealed.

2.

The Colorado Department of Public Health and Environment should continue collecting data from all registered direct-entry midwives including, but not limited to:

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● The number of deliveries performed; ● The Apgar scores of delivered infants; ● Any perinatal deaths, including the cause of death and a description of the circumstances. All records concerning live births, fetal deaths, and infant deaths, as well as other statistical reports reported to CDPHE under Section 25.2, C.R.S., and 5 CCR 1006-1, should be considered to be vital statistics records subject to the current confidentiality provisions of Section 25-2-117, C.R.S., and permitted disclosures in Section 11, 5 CCR 1006-1. 3.

Under its current administrative authority, the Office of Direct-Entry Midwifery Registration should add an attestation to the direct-entry midwife application for registration renewal that states the applicant has provided all required data to CDPHE as already required of direct-entry midwives under Colorado law.

4.

CDPHE should continue to explore how to collect transfer data in a way that is useful to public health surveillance and assists the consumer in responsible interpretation of that data.

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