eileen hutton talmor do we drive faster in canada

Do we drive faster in Canada?

Eileen K. Hutton RM, PhD

McMaster University

VU Amsterdam

Size: 9 M km2

Country Information

Canada

• Population: 33.8

• Median age: 41

• Annual births: 368

Netherlands

16.7 million

41 years

185 thousand

Birthing Information

Canada

• Fertility rate: 1.6

• Birth Rate: 10.3

• Infant mortality: 5

Netherlands

1.7 per 1000 women

10.3 per 1000

4.7 per 1000 births

Maternity care in Canada

• Increasingly obstetricians doing primary care

obstetrics

– 1996: 56% Vaginal Births by OB

– 2000: 61% Vaginal Births by OB

• Large shift of GP physicians out of obstetrics

– 1989 31%

– 1999 19%

Midwifery care in Canada

• More midwives educated and registered

– First regulated midwifery 1994

– Education 4 year BHSc (Midwifery)

• Now 1,000 midwives in country

The Midwifery Model of Care

• Built on principles of:

– woman-centred care– informed choice– evidence based practice– continuity of care provider– choice of birth place.

Source: Canadian Association of Midwives

Like the NL:

– A primary care model of midwifery– Autonomous care providers – Care during pregnancy, birth to 6 weeks post

partum– Community-based; hospital privledges– Self employed– Collaborative with specialists– List of required consultations and transfers of

care

Unlike the NL

• All midwives must provide care in all

settings

• Midwives provide care after consultation

and supportive care after transfer of care

in labour

– Enhances continuity of care

Continuity of Care

• is an important tenant of midwifery care – Same midwife or small group (<4) midwives

provide care:• during all trimesters of pregnancy• Labour & birth and the postpartum period• 24-hour coverage

Source: College of Midwives of British Columbia

Continuity of Care

Allows midwife to:– Develop a relationship during pregnancy – Supportive care in labour and birth – Provide comprehensive care throughout the

postpartum period– Enhance safe, individualised care

Source: College of Midwives of British Columbia

Continuity of Care

• Midwifery care includes:– Family planning

services – Education– Counseling– Advocacy and– Emotional support

Source: College of Midwives of British Columbia

Unlike the NL

• Prenatal care visits 30-45 minutes long

• Case load? Hard to compare

• 2 midwives at the birth

– No kraamverzorgster

Unlike the NL

• Many midwives travel longer distances to

attend births

• 30 minute general rule, but…

• Rural births registered with EMS

Changes in practice patterns

• Research evidence has led to changes in

care protocols

• Populations of women are different

– Many more first time mothers

– More over weight women

– Older birthing population

But are they normal?

• Resulting in changes in :

– Management of PROM

– Rates of induction for post dates

– More slow to progress labours

– GBS management protocols

Canadian midwives provide care in “grey areas”

– Broader scope of screening tests;

– Broader pharmacopeia;

– Labour Induction and augmentation;

– Women with epidural analgesia;

– Electronic fetal heart monitoring

Canadian midwives provide care in “grey areas”

– Resulting in greater continuity of care provider

for women

Benefits of Midwifery Care

• Cochrane review of continuity of care

models shown to decrease CS

• Vaginal deliveries are associated with a

lower risk of maternal morbidity and

infection and shorter hospital stays.

Hodnett E. Cochrane Systematic Review 2006:1

Canadian outcomes at home

Ontario

• 130,000 births per year in Ontario

• Midwives attended 10% of these births

• Home births accounted for 2% of the

provincial total

Typical home birth set up

Ontario

Planned at the onset of labour

6692 homebirth 6692 hospital birth

25, 720 births

Sample Selection

Ontario

• Of all planned homebirths:

– 78% actually delivered at home

• (60% nullip; 89% multip)

– 5% transported by ambulance to hospital

during or immediately following birth

Ontario

Primary outcome - composite of

neonatal/perinatal mortality or serious

morbidity:

– no difference between the home and hospital

2.4% vs. 2.9% RR 0.83 [ 0.67, 1.02 ]

– Both groups reported a perinatal / neonatal

mortality rate of 1:1000

Ontario

Primary outcome - composite of

neonatal/perinatal mortality or serious

morbidity:

– no difference between the home and hospital

2.4% vs. 2.9% RR 0.83 [ 0.67, 1.02 ]

– Both groups reported a perinatal / neonatal

mortality rate of 1:1000

Ontario

– There were no cases of maternal mortality

– Planned homebirth associated with:

• less serious morbidity 5.5% vs. 7.1%;

RR 0.77 [ 0.67, 0.87 ]

Ontario

– There were no cases of maternal mortality

– Planned homebirth associated with:

• less serious morbidity 5.5% vs. 7.1%;

RR 0.77 [ 0.67, 0.87 ]

Ontario

– There were no cases of maternal mortality

– Planned homebirth associated with:

• less serious morbidity 5.5% vs. 7.1%;

RR 0.77 [ 0.67, 0.87 ]

• fewer Caesarean section 5% vs. 8%

RR 0.64 [ 0.56, 0.73 ]

Ontario

Women planning home birth were less likely

to experience:

• Labour augmentation

– 28% vs. 36%; RR 0.76 [ 0.72, 0.80 ]

• Pharmaceutical pain relief

– 17% vs. 45% RR: 0.37 [ 0.35, 0.39 ]

Ontario

• Episiotomy

– 4% vs. 6%; RR: 0.73 [ 0.63; 0.84 ]

• Assisted vaginal delivery

– 3% vs. 4%; RR 0.67 [ 0.56; 0.80 ]

• Caesarean section

– 5% vs. 8%; RR 0.64 [ 0.56, 0.73 ]

IPE – in education programs•ALARM for residents and MW students•Consultation workshop•Introduction to OB for medical students and MW students•Placement with OB, Nursing

IPE – for practitioners •ALARM Course•MOREob

•M&M rounds•Coroner’s review•Perinatal outreach

Do we drive faster in Canada?

Do we drive faster in Canada?

Only sometimes!