Maternal and Child Health Journal

, Volume 23, Issue 1, pp 92–99 | Cite as

Investigation of Predictors of Newborn Screening Refusal in a Large Birth Cohort in North Dakota, USA

  • Grace Njau
  • Agricola OdoiEmail author


Objectives The objective of this study was to identify maternal and provider predictors of newborn screening (NBS) refusal in North Dakota between 2011 and 2014. Methods Records of 40,440 live resident births occurring in North Dakota between 2011 and 2014 were obtained from the North Dakota Department of Health and included in the study. Factor-specific percentages of NBS refusals and 95% confidence intervals were computed for each predictor. Since the outcome is rare, multivariable Firth logistic regression was used to investigate maternal and provider predictors of NBS refusal. Model goodness-of-fit test was evaluated using the Hosmer–Lemeshow test. All analyses were conducted in SAS 9.4. Results Of the 40,440 live births, 135 (0.33%) were NBS refusals. 97% of the refusals were to white women, 94% were homebirths, and 93% utilized state non-credentialed birth attendants. The odds of NBS refusals were significantly higher among non-credentialed birth attendants (p < 0.0001), homebirths (p < 0.0001), and among those that refused Hepatitis B vaccination (HBV) at birth (p = 0.047). On the other hand, odds of NBS refusals were significantly (p < 0.0001) lower among women that had more prenatal visits. Conclusions for Practice This study provides preliminary evidence of association between NBS refusal and provider type, home births, and HBV refusal. Additional studies of obstetric providers, home births and women are needed to improve our understanding of the reasons for NBS refusal to better deliver preventive services to newborns.


Newborn screening Parental refusal Firth models Logistic regression North Dakota Non-credentialed birth attendants Homebirths Lay midwives 



The authors gratefully acknowledge the contributions of the following individuals from North Dakota Department of Health: Carmell Barth (for providing the birth certificate dataset), Anna Power (for de-identifying the Newborn Screening and birth certificate datasets and assisting with data management), and Joyal Meyer (for providing technical assistance on North Dakota’s newborn screening logistics).

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

This study was reviewed and approved as exempt by both the ND Department of Health (NDDoH) (Approval Number: ND-014-42016) and the University of Tennessee, Knoxville Institutional Review Boards (IRB) (Approval Number: UTK IRB-17-04027-XM). Thus, the study has been performed in accordance with ethical standards laid down in the 1964 Helsinki Declaration and its later amendments. No identifying information was available in study data and all results are presented in aggregated form to ensure study subjects cannot be identified.


  1. Advanced Practice Registered Nurse NDCC § 54-05-03.1, 54-05-03.1 C.F.R. § 1 (2016a).Google Scholar
  2. American College of Medical Genetics Newborn Screening Expert Group. (2006). Newborn screening: Toward a uniform screening panel and system–executive summary. Pediatrics, 117(5 Pt 2), S296–S307. Scholar
  3. Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: Why women in the United States choose home birth. Journal of Midwifery & Women’s Health, 54(2), 119–126. doi.CrossRefGoogle Scholar
  4. Centers for Disease Control and Prevention. (2012). CDC Grand Rounds: Newborn screening and improved outcomes. MMWR Morb Mortal Wkly Rep, 61(21), 390–393.Google Scholar
  5. Committee on Genetics. (2015). Committee opinion no. 616: Newborn screening and the role of the obstetrician-gynecologist. Obstetrics and Gynecology, 125(1), 256–260. Scholar
  6. Dempsey, A. F., Schaffer, S., Singer, D., Butchart, A., Davis, M., & Freed, G. L. (2011). Alternative vaccination schedule preferences among parents of young children. Pediatrics, 128(5), 848–856. Scholar
  7. Firth, D. (1993). Bias reduction of maximum-likelihood-estimates. Biometrika, 80(1), 27–38.CrossRefGoogle Scholar
  8. Green, N. S., Dolan, S. M., & Murray, T. H. (2006). Newborn screening: complexities in universal genetic testing. American Journal of Public Health, 96(11), 1955–1959. Scholar
  9. Grosse, S. D., Thompson, J. D., Ding, Y., & Glass, M. (2016). The use of economic evaluation to inform newborn screening policy decisions: The Washington state experience. The Milbank Quarterly, 94(2), 366–391. Scholar
  10. Hamrick, H. J., Gable, E. K., Freeman, E. H., Dunn, L. L., Zimmerman, S. P., Rusin, M. M., … Skinner, A. C. (2016). Reasons for refusal of newborn vitamin K prophylaxis: Implications for management and education. Hospital Pediatrics, 6(1), 15–21. Scholar
  11. Heinze, G. (2006). A comparative investigation of methods for logistic regression with separated or nearly separated data. Statistics in Medicine, 25, 4216–4226.CrossRefGoogle Scholar
  12. Heinze, G., & Schemper, M. (2002). A solution to the problem of separation in logistic regression. Statistics in Medicine, 21(16), 2409–2419. doi.CrossRefGoogle Scholar
  13. Larsson, A., & Therrell, B. L. (2002). Newborn screening: The role of the obstetrician. Clinical Obstetrics and Gynecology, 45(3), 697–710 (discussion 730–692).CrossRefGoogle Scholar
  14. Marcewicz, L. H., Clayton, J., Maenner, M., Odom, E., Okoroh, E., Christensen, D., … Grant, A. (2017). Parental refusal of vitamin K and neonatal preventive services: A need for surveillance. Maternal and Child Health Journal, 21(5), 1079–1084. Scholar
  15. Newborn Screening Clearing House. (2017). Conditions screened by state. Retrieved from
  16. North Dakota Department of Health. (2016). Women, infants and children (WIC). Retrieved from
  17. Omer, S. B., Salmon, D. A., Orenstein, W. A., deHart, M. P., & Halsey, N. (2009). Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. New England Journal of Medicine, 360(19), 1981–1988. Scholar
  18. Phadke, V. K., Bednarczyk, R. A., Salmon, D. A., & Omer, S. B. (2016). Association between vaccine refusal and vaccine-preventable diseases in the United States: A review of measles and pertussis. JAMA, 315(11), 1149–1158. Scholar
  19. Physicians and Surgeons NDCC 43 § 17, NDCC 43 § 17 C.F.R. § 1 (2016b).Google Scholar
  20. Rose, N. C., & Dolan, S. M. (2012). Newborn screening and the obstetrician. Obstetrics and Gynecology, 120(4), 908–917. Scholar
  21. Sahni, V., Lai, F. Y., & MacDonald, S. E. (2014). Neonatal vitamin K refusal and nonimmunization. Pediatrics, 134(3), 497–503. Scholar
  22. Salmon, D. A., Sotir, M. J., Pan, W. K., Berg, J. L., Omer, S. B., Stokley, S., … Halsey, N. A. (2009). Parental vaccine refusal in Wisconsin: A case-control study. Wisconsin Medical Journal, 108(1), 17–23.Google Scholar
  23. Schoendorf, K. C., & Branum, A. M. (2006). The use of United States vital statistics in perinatal and obstetric research. American Journal of Obstetrics and Gynecology, 194(4), 911–915. Scholar
  24. Schulte, R., Jordan, L. C., Morad, A., Naftel, R. P., Wellons, J. C. 3rd, & Sidonio, R. (2014). Rise in late onset vitamin K deficiency bleeding in young infants because of omission or refusal of prophylaxis at birth. Pediatric Neurology, 50(6), 564–568. Scholar
  25. Testing and Treatment of Newborns, 25 § 17 C.F.R. § 25-17 (2001).Google Scholar
  26. Tran, K., Banerjee, S., Li, H., Noorani, H. Z., Mensinkai, S., & Dooley, K. (2007). Clinical efficacy and cost-effectiveness of newborn screening for medium chain acyl-CoA dehydrogenase deficiency using tandem mass spectrometry. Clinical Biochemistry, 40(3–4), 235–241. Scholar
  27. U.S. Census Bureau. (2014). QuickFacts North Dakota. Retrieved from
  28. Vedam, S., & Kolodji, Y. (1995). Guidelines for client selection in the home birth midwifery practice. Journal of Nurse-Midwifery, 40(6), 508–521.CrossRefGoogle Scholar
  29. Williams, R. (2017). Analyzing rare events with logistic regression. Retrieved from

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Family HealthNorth Dakota Department of HealthBismarckUSA
  2. 2.Biomedical and Diagnostic Sciences, College of Veterinary MedicineThe University of TennesseeKnoxvilleUSA

Personalised recommendations