This document summarizes several studies comparing birthing outcomes between home births attended by midwives and hospital births in Ontario, Canada. The studies found that planned home births with midwives had similar rates of neonatal mortality and morbidity as hospital births. However, home births were associated with less medical intervention like induction, epidurals, episiotomies and C-sections. Additionally, a review of midwifery care in Canada found that midwives provide holistic care focused on informed choice, continuity of care and evidence-based practice.

1. Do we drive faster in Canada?
Eileen K. Hutton RM, PhD
McMaster University
VU Amsterdam

2. Size: 9 M km2

8. Country Information
Canada Netherlands
• Population: 33.8 16.7 million
• Median age: 41 41 years
• Annual births: 368 185 thousand

9. Birthing Information
Canada Netherlands
• Fertility rate: 1.6 1.7 per 1000 women
• Birth Rate: 10.3 10.3 per 1000
• Infant mortality: 5 4.7 per 1000 births

10. 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%

11. Midwifery care in Canada
• More midwives educated and registered
– First regulated midwifery 1994
– Education 4 year BHSc (Midwifery)
• Now 1,000 midwives in country

12. 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

13. 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

14. 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

15. 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

16. 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

17. Continuity of Care
• Midwifery care
includes:
– Family planning
services
– Education
– Counseling
– Advocacy and
– Emotional support
Source: College of Midwives of British Columbia

18. Unlike the NL
• Prenatal care visits 30-45 minutes long
• Case load? Hard to compare
• 2 midwives at the birth
– No kraamverzorgster

19. Unlike the NL
• Many midwives travel longer distances to
attend births
• 30 minute general rule, but…
• Rural births registered with EMS

20. 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

21. 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

22. 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

23. Canadian midwives provide care in
“grey areas”
– Resulting in greater continuity of care provider
for women

24. 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

25. Canadian outcomes at home

26. Ontario
• 130,000 births per year in Ontario
• Midwives attended 10% of these births
• Home births accounted for 2% of the
provincial total

27. Typical home birth set up

28. Ontario
Sample Selection
25, 720 births
Planned at the onset of labour
6692 homebirth 6692 hospital birth

29. 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

30. 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

31. 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

32. 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 ]

33. 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 ]

34. 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 ]

35. 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 ]

36. 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 ]

38. 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

39. IPE – for practitioners
•ALARM Course
•MOREob
•M&M rounds
•Coroner’s review
•Perinatal outreach

40. Do we drive faster in Canada?

41. Do we drive faster in Canada?
Only sometimes!