Ontario Midwives Support Birth Centres

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The Association of Ontario Midwives supports the development of birth centres in Ontario. The AOM envisions birth centres as midwifery-led and freestanding sites where midwives, as primary care providers, give women and their families comprehensive prenatal, labour, birth and postpartum care.

Birth is the leading reason for hospitalization of women in Ontario,[1] yet there is no medical reason for the vast majority of women to be hospitalized for labour and birth. As sites that support optimal health for women and newborns, birth centres (in addition to home birth) provide safe, excellent and cost-effective[2] alternatives to hospital-based labour and delivery units.

Safe, Excellent Care for Women and Newborns

In Ontario, midwifery is an integrated part of the maternity care system. With a proven safety record,[3] seamless systems for transporting women in labour, and hospital privileges, the model of midwifery care is already well-suited to practice in birth centre settings. Birth centres could serve as community hubs with a focus on providing care within a health promotion model. Care would be offered from conception through birth to six-weeks postpartum; this continuity of care, already provided by midwives in home and hospital, contributes to excellent outcomes.[4]

Research has shown that a planned out-of-hospital birth is at least as safe as a hospital birth for low-risk women.[5] In fact, there are benefits to out-of-hospital birth for both women and newborns.[6] Research demonstrates that birth centres have lower intervention rates, including a decrease in rates of forceps and vacuum delivery, as well as lower rates of perineal injury and c-section.[7] Growing rates of interventions, including c-section rates, concerns midwives. Research has shown increases in c-section rates in North America have not improved overall outcomes; in fact, the increased rate of c-sections has been indexed to poorer outcomes, such as an increased risk of maternal mortality and morbidity.[8]  Birth centres provide an alternative to hospital birth – an alternative with the potential to decrease intervention rates and to contribute to excellent health outcomes for women and newborns.

Because freestanding birth centres keep healthy populations out of hospital, they contribute to infection control measures, particularly during outbreaks of influenza and other respiratory illnesses. Freestanding birth centres do not face the problem of hospital-based infections produced by antibiotic-resistant bacteria such as MRSA. This is yet another way in which they promote the overall health of Ontario’s population.

Efficient Use of Health Care Resources

As Ontario faces rising health care costs, innovative ways to ensure the sustainability of a universal health care system are needed. The development of birth centres offers such an innovation. Research from the U.S., U.K., Quebec and Australia demonstrates the cost-effectiveness of birth centres when compared to hospital births.[9] Birth centres create savings in the health care system because of their potential to make a real difference in Ontario’s rising intervention rates, such as epidural use, instrumental deliveries and c-sections. The World Health Organization indicates that an adequate c-section rate should be between 5% and 15%,[10] yet Ontario’s overall c-section rate in 2006-07 was 28.4%.[11] Birth centres help decrease these rates because they promote and support birth as a normal, physiologic process. When women have the opportunity to birth in an out-of-hospital environment, the rate of medically unnecessary interventions is reduced, producing a significant cost savings to the health care system without compromising optimal, evidence-based care.

Client Satisfaction

Birth centres improve choices for pregnant women and their families by providing them with a viable, safe, out-of-hospital alternative. Midwives have heard from their clients that women and families want birth centres as an option in Ontario.

Midwifery in Canada has been proven to deliver a high degree of satisfaction for women and their families.[12] Internationally, women who have given birth in birth centres also report very high rates of satisfaction with the experience. In one qualitative study of a U.K. birth centre, 86% of mothers reported that they would have another baby at the birth centre and 96% said they would recommend the birth centre to a friend.[13]

Interprofessional Education Birth centres could act as excellent sites for interprofessional education. As faculties of medicine and nursing look to collaborate with faculties of midwifery to offer education across disciplines, birth centres would offer an excellent setting for students to learn about promoting and supporting normal birth. Students of all health professions would benefit from learning in an environment where low risk normal births are managed using midwifery principles, such as choosing the lowest intervention possible supported by the evidence. 

Conclusion

The Association of Ontario Midwives supports the development of freestanding, midwifery-led birth centres as community hubs for the delivery of high-quality, cost-effective maternal and newborn care. Birth centres not only positively enhance the experience and health of women and their families, but also significantly benefit and support the long-term sustainability of the health care system.



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[1] Canadian Institute for Health Information. Giving birth in Canada: a regional profile,2004.
[2] Debra J. Jackson, Janet M. Lang, William H. Swartz, Theodore G. Ganiats, Judith Fullerton, Jeffrey Ecker, Uyensa Nguyen, MPH. “Outcomes, Safety, and Resource Utilization in a Collaborative Care Birth Center Program Compared With Traditional Physician-Based Perinatal Care.” American Journal of Public Health. June 2003, Vol 93, No. 6: 999-1006; Walker, P.H. and Stone P.W.  “Exploring Cost and Quality: Community-Based versus Traditional Hospital Delivery Systems.” Journal of Health Care Finance. Fall 1996, 23, 1. Daniel Reinharz, Régis Blais, William D. Fraser, André-Pierre Contandriopoulos, and L’Équipe d’évaluation des projets-pilotes sages-femmes. Cost-effectiveness of Midwifery Services vs. Medical Services in Quebec. Canadian Journal of Public Health. January-February 2000. vol. 91. no. 1. pp I-12 – I-15.
[3] Ontario Midwifery Program Midwifery Outcomes Report, 2008-09.
[4] Public Health Agency of Canada. Family-Centred Maternity and Newborn Care: National Guidelines.
[5] Hutton, E. K., Reitsma, A. H. and Kaufman, K. (2009), Outcomes Associated with Planned Home and Planned Hospital Births in Low-Risk Women Attended by Midwives in Ontario, Canada, 2003–2006: A Retrospective Cohort Study. Birth 36:180–89; Janssen PA, Saxell  L, Page L,  Klein MC, Liston RM,  Lee SK. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. Can Med Assoc J 2009 181(6-7): 377-83; de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B, Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S.Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. BJOG 2009 116(9):1188-84.
[6] Leslie, M. S., & Romano, A. (2007). Appendix: Birth can safely take place at home and in birthing centers: The coalition for improving maternity services: The Journal of Perinatal Education : An ASPO/Lamaze Publication, 16(l 1), 81S-88S
[7] Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth. Cochrane Database of Systematic Reviews 2005, Issue 1.
[8] Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS. Maternal Mortality and Severe Morbidity Associated with Low-Risk Planned Cesarean Delivery versus Planned Vaginal Delivery At Term. Can Med Assoc J 2007;176:455-60; Rozen G, Ugoni AM, Sheehan PM. A New Perspective on VBAC: A Retrospective Cohort Study. Women Birth 2010; doi:10.1016/j.wombi.2010.04.001
[9] Stone PW,  Zwanziger J,  Hinton Walker P,  Buenting J. Economic analysis of two models of low-risk maternity care: a freestanding birth center compared to traditional care. Research in Nursing & Health. 2000;23(4):279-89; Reinharz D,  Blais R,  Fraser WD,  Contandriopoulos AP.  Cost-effectiveness of midwifery services vs. medical services in Quebec. Canadian Journal of Public Health. 2000 Jan-Feb;  91(1):I12-5; Byrne JP, Crowther CA,  Moss JR. A randomised controlled trial comparing birthing centre care with delivery suite care in Adelaide, Australia. Australian & New Zealand Journal of Obstetrics & Gynaecology. 2000 Aug;40(3):268-74;Ratcliffe J. The economic implications of the Edgeware birth centre. In: Kirkham M, editor.  Birth Centres. .A social model for maternity care. Elsevier Science Limited; 2003
[10] Chalmers B, Mangiaterra V, Porter R. WHO Priniciples of Perinatal Care: The Essential Antenatal, Perinatal, and Postpartum Care Course. Available from: URL:http://www.fims.uwo.ca/NewMedia2007/page63414317.aspx
[11] The Ontario Perinatal Surveillance System Report 2008.
[12] Public Health Agency of Canada. What Mothers Say:  The Canadian Maternity Experiences Survey.
[13] Boulton, M, Chapple, J, Saunders, D. “Evaluating a New Service: Clinical Outcomes and Women’s Assessments of the Edgware Birth Centre.” Birth Centres: A Social Model for Maternity Care, ed. Mavis Kirkham. Elsevier, 2003.