Water Birth Maternal and Neonatal Outcomes Among Midwifery Clients in Alberta, Canada, from 2014 to 2017: A Retrospective Study.

OBJECTIVES: This study sought to evaluate retrospectively the maternal and neonatal outcomes of water births (WBs) managed by Registered Midwives in Alberta compared with traditional or "land" vaginal birth outcomes for clinical evidence or knowledge and to assist in health care management planning. METHODS: This study was a retrospective cohort comparison of maternal and neonatal outcomes of WB (1716) and traditional or land birth (non-WB) (21 320) from selected low-risk maternal cohorts with spontaneous onset of labour and vaginal delivery in Alberta (2014-2017) using Alberta Perinatal Health Program data sets. Anonymized client and patient records linked the Alberta Perinatal Health Program data with inpatient Discharge Abstract Database for newborn and/or maternal personal health number (PHN/ULI) analyzed using SPSS 19.0 software (IBM Corp., Armonk, NY) (Canadian Task Force Classification II-2). RESULTS: The WB group had fewer and less severe perineal lacerations despite increased macrosomia. The non-WB group had increased maternal factors (age <20 years, third- to fourth-degree perineal tears, excessive blood loss) and neonatal factors (Apgar scores <7 at 5 minutes and neonatal intensive care unit admission). No significant difference was identified between the birth groups for maternal age >35 years, primiparous status, maternal fever, maternal puerperal infection, maternal intensive care unit admission, low birth weight, neonatal resuscitation, and neonatal intensive care unit admission <28 days of life. CONCLUSIONS: A low-risk maternal cohort of WBs (1716) managed by midwives had equivalent or improved neonatal outcomes compared with a low-risk maternal cohort of land or traditional births (21 320) managed by midwives and other maternity providers.

Post-Policy Implementation Review of Rapid Fetal Fibronectin (fFN) Testing for Preterm Labour in Alberta.

OBJECTIVES: In 2006, the Alberta Ministry of Health issued a policy to implement fetal fibronectin (fFN) testing as a publicly funded service for pregnant women. The goals were to reduce maternity health care utilization and unnecessary treatment, which would result in cost-savings for the health system by more accurately diagnosing false preterm labour. We conducted a post-policy implementation review to determine whether the policy implementation achieved its goals. METHODS: We assessed the impacts of fFN testing on clinical decision-making for ambulance transfer, hospital admission, and length of hospital stay by comparing these variables between the tested and untested patients. This post-implementation analysis was conducted separately for inpatients and outpatients and for true and false preterm labour, using multilevel regressions with episodes or visits being nested within patients. We then assessed the impact of fFN testing on costs to the health system by using decision-tree models populated with actual data and results from the regressions. RESULTS: The additional information, provided by fFN testing, influenced clinical decision-making. However, physicians placed a greater significance on positive test results than on negative results, which resulted in an inadvertent increase in health care utilization. After including the costs of fFN testing, the total cost to the system increased by $4.2 million (in 2014 Canadian dollars) between 2008 and 2013, with contributions of $700 000 for false labour and $3.5 million for true preterm labour. CONCLUSION: The policy to adopt fFN testing in Alberta did not achieve the intended aims of reducing unnecessary health care utilization to achieve cost-savings for the health system. There was an inherent tendency to err on the side of caution, and physicians were influenced more by positive test results.