281 Emergency Medical System Response to in Home Delivery and Midwife Utilization in the State of Michigan

Abstract

We observed that out-of-hospital deliveries locally have high complication rates. Some cases involved (non-nurse) midwives for which state licensure was not required until 2016. There is scant literature that addresses out-of-hospital deliveries and none that evaluate the interaction of emergency medical services (EMS) and midwives. Our objective was to describe utilization, complications, and outcomes of EMS attended out-of-hospital deliveries in Michigan in 2015. We queried the Michigan EMS Information System (MI-EMSIS) for out-of-hospital deliveries in 2015. We identified candidate cases, using a combination of narrative, demographic and procedural search strategies. Inclusion was birth prior to hospital arrival. We abstracted demographics, birth circumstances, complications, and birth outcome. Duplicate reviews of 20% of cases were performed to assure interrater reliability. Categories of complications were constructed post hoc. Non-viability was defined as <22 weeks gestation, fetal demise as stillborn or failure to resuscitate upon delivery, and extreme prematurity (24-28 week gestational age). First trimester miscarriages were excluded. Michigan Vital Statistics reported 1,577 out-of-hospital (excluding birthing center) births in 2015, of which 1361 were attended by midwives. We identified 228 EMS attended deliveries from 1.6 million MI-EMSIS records. Mothers’ median age was 28 (range 15-41). The majority (59.2%) were white. Most were normal vaginal deliveries on scene or enroute to hospital (92, 40.0%), or delivered prior to EMS arrival (58, 25.4%). Maternal or fetal complications were identified in 71(31.1%) deliveries. Complications included non-viable fetus (13, 5.7%), fetal demise (12, 4.8%), post-partum hemorrhage (8, 3.5%), non-transient apnea (7, 3.0%), and extreme prematurity (7, 3.0%). Midwives attended 32 (14.0%) EMS cases, with complications reported in 20 (62.5%). Complications included post-partum hemorrhage (6); non-transient apnea (4); and fetal demise (3). The complication rate with and without midwife involvement was 62.5% and 26.9%, respectively. EMS deliveries were rare and most were normal vaginal deliveries, but almost a third had complications. Midwife versus non-midwife EMS deliveries had higher complication rates. Midwife attended EMS deliveries were rare, but had high rates of complications including need for critical interventions.