Running head: ACCURACY OF BIRTH ATTENDANT INFORMATION

AccuracyofProvidertypeonTexasBirthCertificateData
forBirthsAttendedbyaCertifiedNurseMidwife
ErinBiscone

CapstoneChair:

KristyMartyn,Ph.D.

CapstoneCommitteeMembers:

MaryJaneLewitt,Ph.D.,RoySimpson,DNP,
JesseBushman,JohnCranmer,DNP

DateofSubmission:

November23,2015

ACCURACY OF BIRTH ATTENDANT IINFORMATION

TableofContents
Abstract..........................................................................................................................................3
Introduction and Background......................................................................................................4
Problem Statement ....4
Objectives and Aims..5
Review of Literature..5
Theorectical Model6
Project and Study Design..7
Methods............8
Settings and Resources...10
Study Population....10
Sources of Data......10
Data Analysis.............11
Quality and Security.......12
Ethics and Human Subject Protection........13
Timeframes.............13
Budget................14
Conclusion....14
References ....15
Apendix A ....18
Apendix B ....20
Apendix C ....21
Apendix D ....22

ACCURACY OF BIRTH ATTENDANT IINFORMATION

Abstract
Certified nurse-midwives (CNMs) have excellent perinatal outcomes and are underutilized in the
United States. CNMs attended approximately 8% of births in the United States in 2012,
according to the data available in the national birth registry. However, this number may not be
accurate due to underreporting of CNM-attended births. Data obtained from the American
College of Nurse-Midwives (ACNM) indicates that births attended by CNMs may be
underreported by as much as 40%. The reasons that births attended by CNMs are underreported
vary and are related to institutional values, policies, and procedures. When the actual rate of
CNM-attended births is measured, the available data in the birth registry will accurately reflect
outcomes attributable to the quality of the midwifery model of care. Increasing the number of
CNM-attended births by reporting them accurately is one step in the process of increasing public
awareness about midwifery care in the United States. It is imperative that institutions improve
the quality of their procedures to accurately report the provider type for all births.
Keywords: Certified nurse-midwives, CNM, birth certificate data, provider type,
midwifery model of care

ACCURACY OF BIRTH ATTENDANT IINFORMATION

Introduction and Background

The word midwife comes from a middle English word meaning with woman (n.d).
With a focus on the needs of needs of women and their families, midwives have the ability to
improve care womens health care and save the lives of childbearing women and children
(Renfrew, 2014). In the United States, the number of women who are cared for during pregnancy
and birth by a midwife continues to rise, but still lags far behind the numbers of other
industrialized countries with lower maternal and perinatal mortality rates (Emons & Luiten, n.d.;
Kutinova, A., 2008).
In 2012, according to the statistics compiled by the National Center for Health Statistics
at the Center for Disease Control (CDC), certified nurse-midwives (CNMs) attended 7.9% of
total births in the U.S., which represent 11.8% of vaginal births (Martin, et al., 2013a). However,
data collected by the American College of Nurse-Midwives (ACNM) indicates that this number
is inaccurate, and that the percentage of CNM-attended births may be much higher (Bushman,
2015).
Problem Statement
Birth certificate data is used to determine the number of births attended by CNMs in the
United States. However, in many sites, CNMs are not listed as the provider on birth certificates
for the deliveries they attend. Births attended by CNMs are then undercounted, the majority of
the public continues to be unaware of work nurse-midwives are doing, and the quality of data
available in the birth registry on maternal and neonatal outcomes by provider type using birth
certificate data is compromised.

ACCURACY OF BIRTH ATTENDANT IINFORMATION

Objectives and Aims

The aim of this project is to improve the quality of reporting of the provider type for
CNM-attended birth in Texas hospitals. The project objectives are broken into two parts. The
objectives for the first phase are

To determine the number of Texas hospitals reporting CNM-attended births in 2012.

To determine the number of CNM-attended births reported for each institution

reporting CNM-attended births in 2012.

To determine the number of CNM practices at each Texas hospital reporting CNMattended births in 2012.

To request and receive CNM practice data on the number of CNM-attended births in
2012 from a minimum of 10 hospital-based CNM practices in Texas.

To compare the data from the CNM practices to the data from the DHSH on the
number of CNM-attended births that occurred in the corresponding institution.

The objectives for the second phase are

To learn about and document CNM practice directors perceptions of institutional

culture and values that may affect the accuracy of data reported to the state

To identify and document hospital policies and procedures surrounding the reporting
of birth certificate data to the state.
Review of Literature

There is a historical precedent for crediting all births in U.S. hospitals to physicians.
Before 1975, all birth certificates for babies born in U.S. hospitals listed a physician as the birth
attendant, despite the facts that hundreds of midwives were attending births in hospitals (Brucker
& Reedy, 2000). Furthermore, in teaching hospitals, midwives have been seen in the past as an

ACCURACY OF BIRTH ATTENDANT IINFORMATION

impediment to medical education, taking away births and procedures from residents, and in
many institutions, this sentiment persists (Dawley, 2000).
Administrators and clerks may not understand the importance of accurate information on
birth certificates and also may not know about the outcomes research that is done using data
from birth certificates (Northam & Knapp, 2006). Walker, Schmuck, and Summers recommend
that midwives be educated about the procedures for submitting birth certificate data and do
research using birth certificate data (2004).
Research consistently confirms that midwives have as good or better perinatal outcomes
as physicians. Johantgen, et al. compared processes and outcomes between CNMs and physician
between 1990 and 2008 in the U. S. and concluded that where there was a difference in a process
or outcome between the two groups, the evidence favored CNMs (2012). The Cochrane Review
examined research on midwifery-led continuity of care compared to physician-led care in Great
Britain, New Zealand, and Australia, and concluded that midwifery-led care has enough benefit
over physician-led care that most women should be offered midwifery care (Sandall, et al.,
2013).
Thecurrentresearchindicatesthatthemidwiferymodelofcareisunderusedinthe
UnitedStates,butthattheproblemmaybeconfoundedbyunderreportingofCNMattended
births.DemonstratingthatthebirthsattendedbyCNMsisbeingunderreported,aswellas
uncoveredthefactorscontributingtounderreporting,couldhelpimprovethequalityofdatain
thebirthregistry.
Theoretical Model
Sheikh, George, and Gilsons theory of person-centered policy and systems research is
based on the principle that [s]ystem change begins and ends with people because people,

ACCURACY OF BIRTH ATTENDANT IINFORMATION

operating in various roles, ultimately make up any system and fundamentally shape how it
works (2014, p.2). They state that health systems are social and political constructs that . . .
provide vital opportunity for tackling social injustice and that health systems are formed and
influenced by human activity and work (Sheikh, George, &Gilson, 2014, p. 2).
Project and Study Design
This project will be a quality improvement project designed to gather information that
could improve the accuracy of data of the birth-attendant type in the Texas birth registry. The
project will have two stages. The first stage will be obtaining raw numbers for CNM-attended
births from the state birth registry and CNM practices. This stage will begin June 1 and end July
Feb 15, 2016 and will be a two-group comparison design. The data will be paired by institution,
so that the state birth registry data and the CNM practice data can be compared institution by
institution for accuracy and quality. The second stage will be to gather information from hospital
clerks and CNM practice directors on contributing, moderating, and mediating factors that aid or
impede accurate data reporting on CNM-attended births. This stage will begin February 15, 2016
and end February 15, 2017. This data will be analyzed for common trends associated with
institutions that have highly accurate reporting of provider type for CNM-attended births, and
well as trends associated with institutions that do not accurately report the provider type for
CNM-attended births. The DNP student investigator will then develop recommendations based
on the project findings.
The final stage will be developing recommendations CNMs can use to improve the quality
of data reporting in their own institutions. The stage will begin by Feb 15, 2017 and end no later
than the project finish data, May 31, 2017.

ACCURACY OF BIRTH ATTENDANT IINFORMATION

Methods
Mixed methods allow for gathering of general information through quantitative methods,
and then for more detailed interpretation of quantitative findings though qualitative study
(McCusker, 2015). Quantitative and qualitative methods are complimentary and will be used in
this quality improvement project to explore complex questions of both the actual difference in
the number of births attended by CNMs and the number reported and the reasons for the
difference (Tavakol & Sandars, 2014).
Quantitative methods
Quantitative methods of data collection use a positivists approach, where there is a single
truth and a quantifiable answer (Tavakol& Sandars, 2014). This project will gather data that is
quantitative:

Number of hospitals with CNM deliveries in 2012 according to the state

Total number of CNM births in hospitals according to the state
Number of hospitals with CNM deliveries according to the CNO at each institution

that recorded one or more births in 2012

Total number of CNM births in hospitals according to the practices

Data will be collected through the Texas Department of State Health Services (DSHS) for
all hospitals reporting CNM-attended births. Data collection from the hospitals and CNM
practices will occur in stages. First, using a list provided by the Texas Hospital Association of all
hospitals reporting one or more births in 2012, the DNP student investigator will to contact the
Labor and Delivery department to ask if any CNMs attended deliveries in their institution in
2012. Second, for any hospitals that confirm that CNMs do attend births at their institution, the
student researcher will request the data on the number of births attended in 2012 from the
practices themselves. The data will then be paired, institution by institution, to compare the
number of births reported by the institutions in the state birth registry for 2012 with the number

ACCURACY OF BIRTH ATTENDANT IINFORMATION

of births the CNM practices documented attending during 2012. Data analysis will be
descriptive, include frequencies and measures of variability. DNP Project Team faculty with
quantitative expertise will guide analysis.
Qualitative methods
Understanding the perspective of the study subjects has the most potential to make a
difference in others lives (Mirriam & Tisdell, 2016). In qualitative methods, the investigator is
the primary instrument for data collection and analysis, because the purpose is understanding
(Mirriam & Tisdell, 2016). Qualitative methods explore the human experience using nonstatistical methods (Borbasi & Jackson, 2015) focused on the experiences of either patients or
healthcare professionals (Ingham-Broomfied, 2015).
This project will include qualitative data to understand the human experiences and
processes surrounding hospital reporting of provider type for birth attendants, including:

Policies and procedures around reporting birth certificate data gathered from

interviewing hospital clerks who submit the data to the state

Policies and internal relationships gathered from CNM practice directors.

Data will be collected by semi-structured interviews (Mirriam & Tisdell, 2016) conducted
by the DNP student investigator using interview guides (Appendix A & B). The interviews will
be conducted in a location that is private and convenient for participants (e.g., office or
conference room at hospital), and will be recorded and transcribed. The transcripts will be
analyzed by the DNP student investigator for common themes focused on knowledge deficit,
internal relationships, policies, or procedures that CNMs could correct or improve at their own
institutions in Texas (Hsieh & Shannon, 2005). The analysis will not produce generalizable
knowledge, and will be specific to Texas. DNP Project Team faculty with qualitative expertise
will guide analysis. The DNP Team faculty and Baylor Faculty Sponsor will assist with

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10

interpretation of the data for recommendations for quality improvement and application to
policy.
Setting and Resources
The project will be carried out by one DNP student investigator, a CNM, who will gather
background information, conduct a literature review, develop processes and tools for collecting
data from the Texas SHDS, ACNM, midwifery practices, and hospital clerks in Texas, and then
collect the data. Resources she will use include the necessary allotment of time, transportation,
and information from ACNM colleagues at both the national and state level.
Study Population
The first stage of the project will be conducted on state birth registry records and records
kept by CNM practices in Texas. With regards to the data from the state, it is anticipated that all
data on all hospital births in 2012, with the provider type of the birth attendant, will be obtained.
For the data from CNM practices, the sampling method will be purposive, nonprobability
sampling from a minimum of 15 practices.
The second stage of the project will involve collecting data from individuals at the
institutions where CNMs attend births. Data on institutional culture, internal relationships and
attitude toward CNMs by surveying a minimum of 10 CNM practice directors using purposive
sampling. Data on institutional policies and procedures that aid or impede accurate reporting of
the provider-type to the Texas SDHS for CNM attended births will be collected by interviews of
a minimum of 6 hospital clerks, also using purposive sampling.
Sources of Data
Available data on CNM-attended births in Texas is available from two sources: the Texas
State Department of Health Services (SDHS) and the midwifery practices themselves. Data from

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11

the Texas SDHS is given to the National Center for Health Statistics at the CDC and combined
with data from other states and the District of Columbia to create a national birth registry. Data
from midwifery practices is often reported to national midwifery organizations as a part of
quality improvement initiatives, such as ACNMs benchmarking project. In 2012, 21 full-scope
practices in Texas participated in benchmarking and reported the number of births, along with
some quality measures, to ACNM.
The next data to be collected is data on institutional culture and attitude toward CNMs.
This is nominal data and will be collected by surveying a minimum of 10 CNM practice directors
(See Appendix A). The last data to be collected is data on institutional policies and procedures
that aid or impede accurate reporting of the provider-type to the Texas SDHS for CNM attended
births. This data is also nominal data and will be collected by interviews of a minimum of 6
hospital clerks (See Appendix B).
Data Analysis
Information gathering is an integral part of quality improvement (Ogrinc, Nelson, Adams,
& O'Hara, 2013). The data collected as a part of information gathering will be varied. First, the
number of births by provider-type from the Texas SHDS for hospitals that privilege CNMs, as
well as the number of CNM-attended birth recorded by 21 midwifery practices in Texas
participating in benchmarking from ACNM, or directly from a minimum of 15 practices
themselves. This data will be interval data. The next data to be collected is data on institutional
culture and attitude toward CNMs. This is nominal, ratio and interval data and will be collected
by surveying a minimum of 10 CNM practice directors (See Appendix A). The last data to be
collected is data on institutional policies and procedures that aid or impede accurate reporting of
the provider-type to the Texas SDHS for CNM attended births. This data is also nominal,

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12

interval, and ratio data and will be collected by interviews of a minimum of 6 hospital clerks
(See Appendix B). The transcripts will be analyzed by the DNP student investigator for common
themes focused on knowledge deficit, internalrelationships,policies, or procedures that CNMs
could correct or improve at their own institutions in Texas (Hsieh & Shannon, 2005). The
analysis will not produce generalizable knowledge, and will be specific to Texas. DNP Project
Team faculty with qualitative expertise will guide analysis. The DNP Team faculty and Baylor
Faculty Sponsor will assist with interpretation of the data for recommendations for quality
improvement and application to policy.
Quality and Security
The data collected will be de-identified, and institutions will not be named in the written
report on the data analysis. Instead, each institution will receive a letter name, so that the data
from the state for Institution A can be paired with the data from the practice at Institution A and
compared. The data will be presented in a written report available to all interested parties and
stakeholders. No identifiable patient information will be accessed or used for this project.
OriginaldatareceivedfromDSHSwillbestoredinalockedfilecabinetatBaylor
CollegeofMedicineaccessibleonlybythefacultysponsor.Deidentifieddata,withanumber
replacingtheinstitutionname,willbestoredonapasswordprotectedcomputer,accessibleonly
bythestudentinvestigator.Thedocumentproducedtoserveasadatakey,linkingtheinstitution
nametotheassignednumber,willbekeptinaseparatelockedfilecabinetatBaylorCollegeof
Medicine,alsoaccessibleonlybythefacultysponsor.
Assoonasthedataisreceived,eachinstitutionwillbeassignedanumber.Theoriginal
datawillgoinalockedfilecabinetaBaylorCollegeofMedicine,andthekey,linkingthe
numbertotheinstitutionname,willbekeptinaseparatelockedfilecabinetatBaylorCollegeof

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13

Medicine.Thedeidentifieddata,whereanumberissubstitutedforeachhospitalsname,willbe
storedonapasswordprotectedcomputer.Thescreenautomaticallylocksafter2minutesand
requiresapasswordtounlockandrequiredapasswordwithletters,numbers,andsymbolsto
unlock.Thedocumentwiththedeidentifieddatawillitselfbepasswordprotected,requiringa
separateanddistinctpasswordtoopenthedocument.
O&O SafeErase 8 will be used to destroy electronic data. This program allows for
utilization of the Guttman method, in which the data will be overwritten 35 times using precisely
defined rules along with fixed and random values. Paper copies containing data will be destroyed
using a Baylor College of Medicine shredder that meets HIPPA standards. CDs will be shredded
using a Baylor College of Medicine specialty shredder for CDs which meets Department of
Defense (DOD) standards. The destruction date will be May 31, 2017.
Ethics and Human Subjects Protection
This project will be a quality improvement project and as such, and the need for an IRB
review has been waived by the Baylor College of Medicine IRB Committee and Emory
University IRB Committee (See Appendixes C and D).
Timeframes
The planning of this project began in January of 2015 and is ongoing. Data collection for
the first stage of the project will take place between September 1, 2015 and February 15, 2016.
Data collection for the second stage will take place between February 15, 2016 and February 15,
2017. The final written analysis of all data and recommendations for Texas CNMs will be
completed by May 31, 2017. All data will be destroyed no later than May 31, 2017.
Budget

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14

The DNP student investigator will bear the cost of any transportation expenses for
traveling to interview hospital clerks. She will also bear the $30 cost of downloading O&O
SafeErase 8 for the destruction of data and any fees associated with receiving data from Texas
DSHS. No other expenses are anticipated.
Conclusion
This Doctor of Nursing Practice (DNP) scholarly project attempts to provide evidence
that the number of CNM-attended births is underreported to the National Center for Health
Statistics at the CDC by examining CNM-attended births in Texas hospitals. When the actual rate
of CNM-attended births is measured, nurse-midwives will be able to accurately demonstrate
outcomes attributable to the quality of the midwifery model of care. A groundbreaking
international series on midwifery published in The Lancet last year overwhelmingly indicates
that midwives and the midwifery model of care are underutilized (Renfrew, et al., 2014). The
authors conclude that increasing the number of midwives providing care centered on
childbearing women and newborns, rather than a fragmented medical approach, is critical to
decreasing perinatal morbidity and mortality (Renfrew, et. al, 2014). However, the series did not
include any research done in the United States, where midwifery care is relatively rare.
Increasing the number of CNM-attended births by reporting them accurately is one step in the
process of awareness and utilization of midwifery care in the United States. In addition, if the
true number of births that CNMs are attending is significantly higher than the current CDC data
reflects, and CNMs are able to document the true numbers not only in Texas, but across the
United States, CNMs and ACNM will have more power and weight with policy makers,
insurance companies, and other professional organizations as they seek to play a more prominent

ACCURACY OF BIRTH ATTENDANT IINFORMATION

role in decision making regarding national policies and guidelines for the optimum care of
women.

15

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16

References
Borbasi, S. & Jackson, D. (2015). Navigating the maze of research: Enhancing nursing and
midwifery practice. Elsevier: Chatswood, NSW, Australia.
Brucker, M. & Reedy, N. J. (2000). Nurse-midwifery: Yesterday, today and tomorrow. The
American Journal of Maternal/Child Nursing. 25(6), 322-326. Retrieved from
https://login.proxy.library.emory.edu/login?url=https://search.ebscohost.com/login.aspx?
direct=true&db=cin20&AN=2001010709&site=ehost-live
Bushman, J. (2015). Birth attendant and birth certificates: Reasons for questioning certificate
accuracy. American College of Nurse-Midwives. Unpublished presentation for use in
general midwifery advocacy.
Dawley, K. (2000). The campaign to eliminate the midwife. The American Journal of Nursing,
100(10), 50-56. Retrieved from http://www.jstor.org/stable/3522317
Emons, J. K. & Luiten, M. I. J. (n.d.) Midwifery in Europe: An inventory in fifteen EU-member
states. The Netherlands: Deloitte & Touche. Retrieved from
http://www.deloitte.nl/downloads/documents/website_deloitte/GZpublVerloskundeinEuro
paRapport.pdf
Hsieh,H.F.,&Shannon,S.E.(2005).Threeapproachestoqualitativecontentanalysis.
QualitativeHealthResearch,15(9),12771288.doi:10.1177/1049732305276687
Ingham-Broomfield, R (2015). A nurses guide to Qualitative Research. Australian Journal of
Advanced Nursing, 32(3), 34-40.
Issel, L. (2014). Health Program Planning and Evaluation. Burlington, MA: Jones & Bartlett
Learning.

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Johantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012).
Comparison of labor and delivery care provided by certified nurse-midwives and
physicians: a systematic review, 1990 to 2008. Women's Health Issues, 22(1), e73-81.
doi: 10.1016/j.whi.2011.06.005
Kutinova, A. (2008) Midwifery in New Zealand: Government policies, provider choice, and
health outcomes (Doctoral dissertation). Retrieved from http://nzae.org.nz/wpcontent/uploads/2011/08/nr1215138029.pdf
Martin, J. A., Hamilton, B. E., Osterman, M. J. K., Curtin, S. C., & Mathews, T. J. (2013). Births:
Final data for 2012. National Vital Statistics Reports, (62) 9. Hyattsville, MD: National
Center for Health Statistics.
Martin, J. A., Wilson, E. C., Osterman, M. J., Saadi, E. W., Sutton, S. & Hamilton, B. E. (2013).
Assessing the quality of medical and health data from the 2003 birth certificate revision:
Results from two states. Retrieved from
http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_02.pdf
McCusker, K. (2015). Research using qualitative quantitative or mixed methods and choice
based on the research. Perfusion, 30(7), 537-542 536p. doi: 10.1177/0267659114559116
Merriam, S. B. & Tisdell, E. J. (2016). Qualitative research: A guide to design and
implementation. Jossey-Bass: San Francisco, CA.
Midwife. (n.d.) In Miriam Webster online. Retrieved from http://www.merriamwebster.com/dictionary/midwife
Northam, S. & Knapp, T. R. (2006). The reliability and validity of birth certificates. Journal of
Obstetric, Gynecologic & Neonatal Nursing. 35(1), 3-12. doi: 10.1111/j.1552609.2006.00016.x

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Ogrinc,G.,Nelson,W.A.,Adams,S.M.,&O'Hara,A.E.(2013).Aninstrumenttodifferentiate
betweenclinicalresearchandqualityimprovement.IRB:AReviewofHumanSubjects
Research,35(5),18
Renfrew, M. J., McFadden, A., Bastos, M. H., Campbell, J., Channon, A. A., Cheung, N. F., . . .
& Declercq, E. (2014). Midwifery and quality care: Findings from a new evidenceinformed framework for maternal and newborn care. The Lancet. 384(9948), 26-27.
Retrieved from doi:10.1016/S0140-6736(14)60789-3
Tavakol, M., & Sandars, J. (2014). Quantitative and qualitative methods in medical education
research: AMEE Guide No 90: Part I. Medical Teacher, 36(9), 746-756. doi:
10.3109/0142159x.2014.915298
Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2013). Midwife-led continuity
models versus other models of care for childbearing women. Cochrane Database of
Systematic Reviews. doi: 10.1002/14651858.CD004667.pub3
Sheikh, K., George, A. & Gilson, L. (2014). People-centered science: Strengthening the practice
of health policy and systems research. Health Research Policy and Systems. 12(19). doi:
10.1186/1478-4505-12-19
Walker, D. S., Schmunk, S. B., & Summers, L. (2004). Do birth certificate data accurately reflect
the number of CNM-attended births? An exploratory study. Journal of Midwifery &
Womens Health, 49(5), 443-8. Retrieved from http://sfxhosted.exlibrisgroup.com/emu?
sid=Entrez%3APubMed&id=pmid%3A15351335&issn=1526-9523

Appendix A

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Texas CNM Practice Director Interview Questions

Interview date _____________

Name of Hospital ___________________

General Nurse-Midwifery Service Information

1. How many nurse-midwives are in your service?
2. How many FTEs do those nurse-midwives represent?
3. How long have nurse-midwives in your service been attending births at your current
hospital?
4. How many births are attended by nurse-midwives in your service in a month?
Internal Institutional Relationships
1. How would you describe the relationship between the nurse- midwives and the OB/Gyns in
the hospital?
2. How would you rate the midwives relationship with the OB/Gyns in the hospital?
3. Can you describe interactions that you think have positively or negatively affected the
relationship between OB/Gyns and nurse-midwives?
4. Have you ever engaged in activities with the express purpose of improving relationships
with physicians in the hospital? If yes, please describe:
5.

How would you describe the relationship between the nurse- midwives and the OB/Gyns in
the hospital?

6. How would you rate the nurse-midwives relationships with hospital administration?
7. Can you describe interactions that you think have positively or negatively affected the
relationship between hospital administrators and nurse-midwives?
8. Have you ever engaged in activities with the express purpose of improving relationships with
hospital administration?

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9. Please describe the nurse-midwives relationship with hospital clerks who submit birth
certificate data to the state?
10. How well do you know the clerks who submit the birth certificate information to the state?
11. Please describe interactions you have had with clerks who submit birth certificate
information to the state.
12. Have you ever spoken to a clerk about the importance of birth certificate information?
13. Have you ever expressed appreciation to a clerk who submits birth certificate information for
the work they do?
Birth Certificate Information
1. Please describe what you know about the process that birth certificate clerks use to submit
birth certificate information to the state.
2. Do you know how the clerks select attending providers for the birth certificates? If yes,
please describe:
3. Are nurse-midwives listed on the birth certificates for the births they attend at your
institution?
4. If nurse-midwives are not listed on the birth certificate, or are only listed on the birth
certificate some of the time, who is listed on the birth certificate as the attendant?
5. Have you ever spoken to hospital administrators about nurse-midwives being listed on birth
certificates for births they attend? If yes, please describe the response you received:
6. What do you think are the needs or issues related to the quality of data reporting for nursemidwife attended-births?
7. What are the possible solutions to improving the quality birth certificate data for the
provider-type for nurse-midwife-attended births?

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Appendix B
Texas Hospital Clerk Interview Questions
Interview date _____________

Name of Hospital ___________________

1. What types of providers attend deliveries at your hospital?

2. Describe the procedure you use to identify the provider at each birth in your hospital?
3. How do you determine the name of the provider to list on a birth certificate as the attendant?
4. If you select a providers name in the system, are the credentials for that provider
automatically associated with the name, or do you also need to select whether the provider is
an MD, DO, CNM, etc.?
5. Are you familiar with certified nurse-midwives (CNMs)?
6. Have you ever met the CNMs that work here in this hospital?
7. How do you determine when or if to check the box for CNM on the birth certificate form?
8. What do you think could be done to help make sure that when a CNM attends a birth, s/he is
listed on the birth certificate as the provider (at this hospital, or in general)?

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Appendix C

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AppendixD

23