Eileen Hutton TALMOR Do we drive faster in canada
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Transcript of Eileen Hutton TALMOR Do we drive faster in canada
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Do we drive faster in Canada?
Eileen K. Hutton RM, PhD
McMaster University
VU Amsterdam
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Size: 9 M km2
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Country Information
Canada
• Population: 33.8
• Median age: 41
• Annual births: 368
Netherlands
16.7 million
41 years
185 thousand
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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
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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%
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Midwifery care in Canada
• More midwives educated and registered
– First regulated midwifery 1994
– Education 4 year BHSc (Midwifery)
• Now 1,000 midwives in country
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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
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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
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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
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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
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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
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Continuity of Care
• Midwifery care includes:– Family planning
services – Education– Counseling– Advocacy and– Emotional support
Source: College of Midwives of British Columbia
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Unlike the NL
• Prenatal care visits 30-45 minutes long
• Case load? Hard to compare
• 2 midwives at the birth
– No kraamverzorgster
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Unlike the NL
• Many midwives travel longer distances to
attend births
• 30 minute general rule, but…
• Rural births registered with EMS
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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
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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
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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
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Canadian midwives provide care in “grey areas”
– Resulting in greater continuity of care provider
for women
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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
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Canadian outcomes at home
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Ontario
• 130,000 births per year in Ontario
• Midwives attended 10% of these births
• Home births accounted for 2% of the
provincial total
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Typical home birth set up
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Ontario
Planned at the onset of labour
6692 homebirth 6692 hospital birth
25, 720 births
Sample Selection
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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
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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
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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
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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 ]
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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 ]
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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 ]
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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 ]
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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 ]
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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
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IPE – for practitioners •ALARM Course•MOREob
•M&M rounds•Coroner’s review•Perinatal outreach
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Do we drive faster in Canada?
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Do we drive faster in Canada?
Only sometimes!