Abortion Safety and Use with Normally Prescribed Mifepristone in Canada.

BACKGROUND: In the United States, mifepristone is available for medical abortion (for use with misoprostol) only with Risk Evaluation and Mitigation Strategy (REMS) restrictions, despite an absence of evidence to support such restrictions. Mifepristone has been available in Canada with a normal prescription since November 2017. METHODS: Using population-based administrative data from Ontario, Canada, we examined abortion use, safety, and effectiveness using an interrupted time-series analysis comparing trends in incidence before mifepristone was available (January 2012 through December 2016) with trends after its availability without restrictions (November 7, 2017, through March 15, 2020). RESULTS: A total of 195,183 abortions were performed before mifepristone was available and 84,032 after its availability without restrictions. After the availability of mifepristone with a normal prescription, the abortion rate continued to decline, although more slowly than was expected on the basis of trends before mifepristone had been available (adjusted risk difference in time-series analysis, 1.2 per 1000 female residents between 15 and 49 years of age; 95% confidence interval [CI], 1.1 to 1.4), whereas the percentage of abortions provided as medical procedures increased from 2.2% to 31.4% (adjusted risk difference, 28.8 percentage points; 95% CI, 28.0 to 29.7). There were no material changes between the period before mifepristone was available and the nonrestricted period in the incidence of severe adverse events (0.03% vs. 0.04%; adjusted risk difference, 0.01 percentage points; 95% CI, -0.06 to 0.03), complications (0.74% vs. 0.69%; adjusted risk difference, 0.06 percentage points; 95% CI, -0.07 to 0.18), or ectopic pregnancy detected after abortion (0.15% vs. 0.22%; adjusted risk difference, -0.03 percentage points; 95% CI, -0.19 to 0.09). There was a small increase in ongoing intrauterine pregnancy continuing to delivery (adjusted risk difference, 0.08 percentage points; 95% CI, 0.04 to 0.10). CONCLUSIONS: After mifepristone became available as a normal prescription, the abortion rate remained relatively stable, the proportion of abortions provided by medication increased rapidly, and adverse events and complications remained stable, as compared with the period when mifepristone was unavailable. (Funded by the Canadian Institutes of Health Research and the Women's Health Research Institute.).

Diabetes mellitus in pregnancy across Canada.

BACKGROUND: Contemporary estimates of diabetes mellitus (DM) rates in pregnancy are lacking in Canada. Accordingly, this study examined trends in the rates of type 1 (T1DM), type 2 (T2DM) and gestational (GDM) DM in Canada over a 15-year period, and selected adverse pregnancy outcomes. METHODS: This study used repeated cross-sectional data from the Canadian Institute of Health Information (CIHI) hospitalization discharge abstract database (DAD). Maternal delivery records were linked to their respective birth records from 2006 to 2019. The prevalence of T1DM, T2DM and GDM were calculated, including relative changes over time, assessed by a Cochrane-Armitage test. Also assessed were differences between provinces and territories in the prevalence of DM. RESULTS: Over the 15-year study period, comprising 4,320,778 hospital deliveries in Canada, there was a statistically significant increase in the prevalence of GDM and T1DM and T2DM. Compared to pregnancies without DM, all pregnancies with any form of DM had higher rates of hypertension and Caesarian delivery, and also adverse infant outcomes, including major congenital anomalies, preterm birth and large-for-gestational age birthweight. CONCLUSION: Among 4.3 million pregnancies in Canada, there has been a rise in the prevalence of DM. T2DM and GDM are expected to increase further as more overweight women conceive in Canada.

Maternal deaths by suicide and drug overdose in two Canadian provinces; retrospective review.

OBJECTIVE: To identify and review factors associated with maternal deaths by suicide and drug overdose in the Canadian Coroner and Medical Examiners Database (CCMED), from 2017-2019. METHODS: We identified potential maternal deaths in Ontario and British Columbia by searching the CCMED narratives of deaths to females 10 to 60 years old for pregnancy-related terms. Identified narratives were then qualitatively reviewed in quadruplicate to determine if they were maternal deaths by suicide or drug overdose, and to extract information on maternal characteristics, the manner of death, and factors associated with each death. RESULTS: Of the 90 deaths identified in this study, 15 (16.7%) were due to suicide and 20 (22.2%) were due to a drug overdose. These deaths occurred to women of varying ages and across the pregnancy-postpartum period. Among the suicides, 10 were by hanging, and among the overdose-related deaths, 15 had fentanyl detected. Notably, 13 (37.1%) of the 35 deaths to suicide or drug overdose occurred beyond 42 days after pregnancy, 19 (54.3%) followed a miscarriage or induced abortion, and in 23 (65.7%) there was an established history of mental health illness. Substance use disorders were documented in 4 of the 15 suicides (26.7%), and 18 of the 20 overdose-related deaths (90.0%). CONCLUSION: Suicide and drug overdose may contribute more to maternal deaths in Canada than previously realized. Programs are needed to identify women at risk of these outcomes, and to intervene during pregnancy and beyond the conventional postpartum period.

A mixed-method study exploring barriers and facilitators to midwives' mental health in Ontario.

BACKGROUND: There is a paucity of information regarding the mental health of midwives working in Ontario, Canada. Many studies have investigated midwives' mental health around the world, but little is known about how the model of midwifery care in Ontario contributes to or negatively impacts midwives' mental health. The aim of the study was to gain a deeper understanding of factors that contribute to and negatively impact Ontario midwives' mental health. METHODS: We employed a mixed-methods, sequential, exploratory design, which utilized focus groups and individual interviews, followed by an online survey. All midwives in Ontario who had actively practiced within the previous 15 months were eligible to participate. FINDINGS: We conducted 6 focus groups and 3 individual interviews, with 24 midwives, and 275 midwives subsequently completed the online survey. We identified four broad factors that impacted midwives' mental health: (1) the nature of midwifery work, (2) the remuneration model, (3) the culture of the profession, and (4) external factors. DISCUSSION: Based on our findings and the existing literature, we have five broad recommendations for improving Ontario midwives' mental health: (1) provide a variety of work options for midwives; (2) address the impacts of trauma on midwives; (3) make mental health services tailored for midwives accessible; (4) support healthy midwife-to-midwife relationships; and (5) support improved respect and understanding of midwifery. CONCLUSION: As one of the first comprehensive investigations into midwives' mental health in Ontario, this study highlights factors that contribute negatively to midwives' mental health and offers recommendations for how midwives' mental health can be improved systemically.

Exploring patients' perspectives of gestational diabetes mellitus screening and counselling in Ontario: A grounded theory study.

INTRODUCTION: Gestational diabetes mellitus (GDM) is associated with adverse perinatal outcomes. Approaches to screening for GDM continue to evolve, introducing potential variability of care. This study explored the impact of these variations on GDM counselling and screening from the perspectives of pregnant individuals. METHODS: Following a Corbin and Strauss approach to qualitative, grounded theory we recruited 28 individuals from three cities in Ontario, Canada who had a singleton pregnancy under the care of either a midwife, family physician or obstetrician. Convenience and purposive sampling techniques were used. Semi-structured telephone interviews were conducted and transcribed verbatim between March and December 2020. Transcripts were analysed inductively resulting in codes, categories and themes. RESULTS: Three themes were derived from the data about GDM screening and counselling: 'informing oneself', 'deciding' and 'screening'. All participants, regardless of geographical region, or antenatal care provider, moved through these three steps during the GDM counselling and screening process. Differences in counselling approaches between pregnancy care providers were noted throughout the 'informing' and 'deciding' stages of care. Factors influencing these differences included communication, healthcare autonomy and patient motivation to engage with health services. No differences were noted within care provider groups across the three geographic regions. Participant experiences of GDM screening were influenced by logistical challenges and personal preferences towards testing. CONCLUSION: Informing oneself about GDM may be a crucial step for facilitating decision-making and screening uptake, with an emphasis on information provision to facilitate patient autonomy and motivation. PATIENT OR PUBLIC CONTRIBUTION: Participants of our study included patients and service users. Participants were actively involved in the study design due to the qualitative, patient-centred nature of the research methods employed. Analysis of results was structured according to the emergent themes of the data which were grounded in patient perspectives and experiences.

The impact of funding models on the integration of Ontario midwives: a qualitative study.

BACKGROUND: Nearly 30 years post legalisation and introduction, midwifery is still not optimally integrated within the health system of Canada's largest province, Ontario. Funding models have been identified as one of the main barriers. METHODS: Using a constructivist perspective, we conducted a qualitative descriptive study to examine how antepartum, intrapartum, and postpartum funding arrangements in Ontario impact midwifery integration. We conceptualized optimal 'integration' as circumstances in which midwives' knowledge, skills, and model of care are broadly respected and fully utilized, interprofessional collaboration and referral support the best possible care for patients, and midwives feel a sense of belonging within hospitals and the greater health system. We collected data through semi-structured telephone interviews with midwives, obstetricians, family physicians, and nurses. The data was examined using thematic analysis. RESULTS: We interviewed 20 participants, including 5 obstetricians, 5 family physicians, 5 midwives, 4 nurses, and 1 policy expert. We found that while course-of-care-based midwifery funding is perceived to support high levels of midwifery client satisfaction and excellent clinical outcomes, it lacks flexibility. This limits opportunities for interprofessional collaboration and for midwives to use their knowledge and skills to respond to health system gaps. The physician fee-for-service funding model creates competition for births, has unintended consequences that limit midwives' scope and access to hospital privileges, and fails to appropriately compensate physician consultants, particularly as midwifery volumes grow. Siloing of midwifery funding from hospital funding further restricts innovative contributions from midwives to respond to community healthcare needs. CONCLUSIONS: Significant policy changes, such as adequate remuneration for consultants, possibly including salary-based physician funding; flexibility to compensate midwives for care beyond the existing course of care model; and a clearly articulated health human resource plan for sexual and reproductive care are needed to improve midwifery integration.

"It's a Little Bit Tricky": Results from the POLYamorous Childbearing and Birth Experiences Study (POLYBABES).

The number of polyamorous people in Canada is growing steadily, and many polyamorous people are of childbearing age and report living with children. Experiences of polyamorous families, particularly those related to pregnancy and childbirth, have thus far been underrepresented in the literature. The POLYamorous Childbearing and Birth Experiences Study (POLYBABES) sought to explore the pregnancy and birth experiences of polyamorous people. Having previously reported findings relating to experiences with the health system and healthcare providers, this article specifically focuses on the social aspects of polyamorous families' experiences. We explored the impact of polyamory on one's self identity, relationship structures, and experiences navigating the social world. Anyone who self-identified as polyamorous during pregnancy and birth, gave birth in Canada within 5 years, and received some prenatal care was eligible to participate in this study. Participants were recruited through social media and interviewed online or in person. Twenty-four participants were interviewed (11 birthing people and 13 of their partners). Thematic analysis was used to explore the data, and four primary themes were identified: deliberately planning families, more is more, presenting polyamory, and living in a mononormative world. Each theme was further broken down into a number of sub-themes. We also collaborated with research participants to create a glossary of terms. By exploring the pregnancy and birth experiences of polyamorous families and focusing on participant voices, this research adds to the limited research on polyamorous families and contributes to the process of breaking down stigma associated with alternative family structures. Further, by creating an accessible glossary of terms, researchers and lay persons alike have been given access to a meaningful resource.

The effect of a new maternity unit on maternal outcomes in rural Haiti: an interrupted time series study.

BACKGROUND: In Haiti where there are high rates of maternal and neonatal mortality, efforts to reduce mortality and improve maternal newborn child health (MNCH) must be tracked and monitored to measure their success. At a rural Haitian hospital, local surveillance efforts allowed for the capture of MNCH indicators. In March 2018, a new stand-alone maternity unit was opened, with increased staff, personnel, and physical space. We aimed to determine if the new maternity unit brought about improvements in maternal and neonatal outcomes. METHODS: We conducted an interrupted time series analysis using data collected between July 2016 and October 2019 including 20 months before the opening of the maternity unit and 20 months after. We examined maternal-neonatal outcomes such as physiological (vaginal) births, caesarean birth, postpartum hemorrhage (PPH), maternal deaths, stillbirths and undesirable outcomes (eclampsia, PPH, perineal laceration, postpartum infection, maternal death or stillbirth). RESULTS: Immediately after the opening of the new maternity, the number of physiological births decreased by 7.0% (ß = - 0.070; 95% CI: - 0.110 to - 0.029; p = 0.001) and there was an increase of 6.7% in caesarean births (ß = 0.067; 95% CI: 0.026 to 0.107; p = 0.002). For all undesirable outcomes, preintervention there was an increasing trend of 1.8% (ß = 0.018; 95% CI: 0.013 to 0.024; p < 0.001), an immediate 14.4% decrease after the intervention (ß = - 0.144; 95% CI: - 0.255 to - 0.033; p = 0.012), and a decreasing trend of 1.8% through the postintervention period (ß = - 0.018; 95% CI: - 0.026 to - 0.009; p < 0.001). No other significant level or trend changes were noted. CONCLUSIONS: The new maternity unit led to an upward trend in caesarean births yet an overall reduction in all undesirable maternal and neonatal outcomes. The new maternity unit at this rural Haitian hospital positively impacted and improved maternal and neonatal outcomes.

Severe maternal morbidity surveillance: Monitoring pregnant women at high risk for prolonged hospitalisation and death.

BACKGROUND: There is no international consensus on the definition and components of severe maternal morbidity (SMM). OBJECTIVES: To propose a comprehensive definition of SMM, to create an empirically justified list of SMM types and subtypes, and to use this to examine SMM in Canada. METHODS: Severe maternal morbidity was defined as a set of heterogeneous maternal conditions known to be associated with severe illness and with prolonged hospitalisation or high case fatality. Candidate SMM types/subtypes were evaluated using information on all hospital deliveries in Canada (excluding Quebec), 2006-2015. SMM rates for 2012-2016 were quantified as a composite and as SMM types/subtypes. Rate ratios and population attributable fractions (PAF) associated with overall and specific SMM types/subtypes were estimated in relation to length of hospital stay (LOS > 7 days) and case fatality. RESULTS: There were 22 799 cases of SMM subtypes (among 1 418 545 deliveries) that were associated with a prolonged LOS or high case fatality. Between 2012 and 2016, the composite SMM rate was 16.1 (95% confidence interval [CI] 15.9, 16.3) per 1000 deliveries. Severe pre-eclampsia and HELLP syndrome (514.6 per 100 000 deliveries), and severe postpartum haemorrhage (433.2 per 100 000 deliveries) were the most common SMM types, while case fatality rates among SMM subtypes were highest among women who had cardiac arrest and resuscitation (241.1 per 1000), hepatic failure (147.1 per 1000), dialysis (67.6 per 1000), and cerebrovascular accident/stroke (51.0 per 1000). The PAF for prolonged hospital stay related to SMM was 17.8% (95% CI 17.3, 18.3), while the PAF for maternal death associated with SMM was 88.0% (95% CI 74.6, 94.4). CONCLUSIONS: The proposed definition of SMM and associated list of SMM subtypes could be used for standardised SMM surveillance, with rate ratios and PAFs associated with specific SMM types/subtypes serving to inform clinical practice and public health policy.

Resident Attitudes Towards Caesarean Delivery in Canadian Obstetrics and Gynaecology Residency Programs.

OBJECTIVE: This study aimed to explore the attitudes of obstetrics and gynaecology residents in Canada towards interventions that influence caesarean section rates. The study looked at residents' attitudes towards four guidelines that support vaginal and assisted delivery (vaginal birth after caesarean section, induction of labour, operative vaginal birth, and fetal health surveillance in labour) and towards Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines in general. The study also sought to investigate whether these attitudes vary by residency training location. METHODS: An online survey of obstetrics and gynaecology residents across Canada was conducted. Residents responded to statements derived from guidelines using a five-point attitudinal scale and to an optional long-answer question about how residency has prepared them to make decisions around interventions. Descriptive summary statistics are used to present the findings (Canadian Task Force Classification III). RESULTS: A total of 27% of residents completed the survey. The majority demonstrated attitudes congruent with guidelines and favourable towards SOGC guidelines in general. Residents attitudes were least favourable towards electronic fetal monitoring, with 67.4% of responses congruent with the guideline. Attitudes were most aligned with the operative vaginal birth guideline, with 87.9% of responses congruent with the guideline. This sample was underpowered to detect statistically significant differences among residency programs, although there was some variation in attitudes across programs, with the most congruent scoring program at 81.8% congruent responses and the lowest at 66.7%. CONCLUSION: Obstetrics and gynaecology residents in Canada have favourable attitudes towards interventions that support vaginal and assisted delivery. There was variability in observed attitudes across programs, although this was not statistically significant.

Sociodemographic Characteristics and Clinical Outcomes of People Receiving Inadequate Prenatal Care: A Retrospective Cohort Study.

OBJECTIVE: This study sought to describe the incidence inadequate prenatal care (IPNC) at an urban level II hospital in Hamilton, Ontario, and to compare the characteristics and outcomes of mothers who received IPNC and their newborns with those who received adequate prenatal care (APNC). This study is the first part of a mixed-methods research program aimed at informing the development of an interdisciplinary, patient-centred, prenatal care program for people who struggle to access conventional modes of care. METHODS: This retrospective cohort study compared mothers and neonates born at St. Joseph's Health Care Hamilton in 2016 with IPNC (fewer than or equal to four antenatal visits, or first visit in third trimester) with those born with APNC (five or more prenatal visits and initial visit before the third trimester). Cases and controls matched 3:1 for age and parity were identified through a retrospective chart review. RESULTS: In total 3235 charts were reviewed, and 69 cases of IPNC were identified (2.1%). The IPNC group had lower education and higher unemployment levels, as well as higher rates of smoking and drug use. Our primary and secondary outcomes of newborn custody loss, neonatal intensive care unit admission, and neonatal length of stay were significantly higher in the IPNC group. CONCLUSION: Patients delivering with IPNC represent a high-risk group with increased rates of adverse neonatal outcomes and newborn custody loss. This quantitative study will inform future research and innovative interdisciplinary program development aimed at increasing access to prenatal care in an effort to improve maternal and neonatal outcomes.

The Polyamorous Childbearing and Birth Experiences Study (POLYBABES): a qualitative study of the health care experiences of polyamorous families during pregnancy and birth.

BACKGROUND: As many as 1 in 5 adults practise some type of consensual nonmonogamy such as polyamory; many are married, have children, or both. Polyamorous families face unique challenges when accessing care during pregnancy and birth, and qualitative descriptive studies are needed to understand their experiences and inform health care providers' practice. METHODS: Participants, who self-identified as polyamorous, had given birth in the last 5 years and received at least some prenatal care, were recruited through convenience sampling on social media. Any of the birthing individual's partners were also invited to participate. All participants completed a short demographic questionnaire and participated in a semistructured interview. Interview transcripts were coded using Braun and Clarke's iterative thematic analysis. RESULTS: A total of 24 participants, 11 who had given birth and 13 partners, were interviewed. Of those who had given birth, 5 received midwifery care only, 4 received obstetric care exclusively and 2 received shared care. Polyamorous families described sharing many common experiences during pregnancy and birth that were affected by their polyamorous identity. Although participants reported both positive and negative experiences with health care providers, when accessing health care all had experienced some form of marginalization that was related to their polyamorous status. One particular challenge for families was with respect to disclosure of polyamorous identity in hospital environments. Participants offered suggestions for improving the health care of polyamorous families during pregnancy and birth, including creating nonjudgmental spaces, accommodating difference through minimizing administrative barriers and allying with patients by providing patient-led care. INTERPRETATION: Polyamorous families face marginalization when accessing pregnancy and birth care. Care experiences for polyamorous families can be improved by nonjudgmental, open attitudes of health care providers, and modifications to hospital policies to support multiparent families.

Access to midwifery care for people of low socio-economic status: a qualitative descriptive study.

BACKGROUND: Despite public funding of midwifery care, people of low-socioeconomic status are less likely to access midwifery care in Ontario, Canada, but little is known about barriers that they experience in accessing midwifery care. The purpose of this study was to examine the barriers and facilitators to accessing midwifery care experienced by people of low-socioeconomic status. METHODS: A qualitative descriptive study design was used. Semi-structured interviews were conducted with 30 pregnant and post-partum people of low-socioeconomic status in Hamilton, Ontario from January to May 2018. Transcribed interviews were coded using open coding techniques and thematically analyzed. RESULTS: We interviewed 13 midwifery care recipients and 17 participants who had never received care from midwives. Four themes arose from the interviews: "I had no idea…", "Babies are born in hospitals", "Physicians as gateways into prenatal care", and "Why change a good thing?". Participants who had not experienced midwifery care had minimal knowledge of midwifery and often had misconceptions about midwives' scope of practice and education. Prevailing beliefs about pregnancy and birth, particularly concerns about safety, drove participants to seek care from a physician. Physicians are the entry point into the health care system for many, yet few participants received information about midwifery care from physicians. Participants who had experienced midwifery care found it to be an appropriate match for the needs of people of low socioeconomic status. Word of mouth was a primary source of information about midwifery and the most common reason for people unfamiliar with midwifery to seek midwifery care. CONCLUSIONS: Access to midwifery care is constrained for people of low-socioeconomic status because lack of awareness about midwifery limits the approachability of these services, and because information about midwifery care is often not provided by physicians when pregnant people first contact the health care system. For people of low-socioeconomic status, inequitable access to midwifery care may be exacerbated by lack of knowledge about midwifery within social networks and a tendency to move passively through the health care system which traditionally favours physician care. Targeted efforts to address this issue are necessary to reduce disparities in access to midwifery care.

Birth Outcomes for Midwifery Clients Who Begin Postdates Induction of Labour Under Midwifery Care Compared With Those Who Are Transferred to Obstetrical Care.

OBJECTIVE: This study sought to compare clinical outcomes of midwifery clients who had postdates induction of labour with oxytocin under midwifery care with those transferred to obstetrical care. METHODS: This was a retrospective cohort study using 2006-2009 Ontario Midwifery Program data. All low-risk Ontario midwifery clients who had postdates oxytocin induction were included. Groups were established according to the planned care provider at onset of induction. The primary outcome was Cesarean section (CS). The secondary outcome was a composite of stillbirth, neonatal death, or serious morbidity. Other outcomes included assisted vaginal delivery, pharmaceutical pain relief, and use of episiotomy. We stratified by parity and used logistic regression to conduct analyses controlling for maternal age (Canadian Task Force Classification II-2). RESULTS: For nulliparas, postdates induction with oxytocin under midwifery care decreased the odds of interventions including assisted vaginal delivery (OR 0.68; 95% CI 0.48-0.97), episiotomy (OR 0.49; 95% CI 0.34-0.70), and pharmaceutical pain relief (OR 0.57; 95% CI 0.36-0.90), with no difference in odds of neonatal morbidity or mortality (OR 0.71; 95% CI 0.25-2.04) when compared with induction under obstetrical care. For multiparas, the use of pharmaceutical pain relief was significantly lower in the midwifery group (OR 0.65; 95% CI 0.44-0.96). CONCLUSION: For low-risk midwifery clients at 41 weeks or more gestation, the odds of Caesarean section and neonatal morbidity and mortality are similar when induction of labour with oxytocin under the care of a midwife is compared with induction of labour under obstetrical care, and rates of intervention are decreased.

Data accuracy in the Ontario birth Registry: a chart re-abstraction study.

BACKGROUND: Ontario's birth Registry (BORN) was established in 2009 to collect, interpret, and share critical data about pregnancy, birth and the early childhood period to facilitate and improve the provision of healthcare. Since the use of routinely-collected health data has been prioritized internationally by governments and funding agencies to improve patient care, support health system planning, and facilitate epidemiological surveillance and research, high quality data is essential. The purpose of this study was to verify the accuracy of a selection of data elements that are entered in the Registry. METHODS: Data quality was assessed by comparing data re-abstracted from patient records to data entered into the Ontario birth Registry. A purposive sample of 10 hospitals representative of hospitals in Ontario based on level of care, birth volume and geography was selected and a random sample of 100 linked mother and newborn charts were audited for each site. Data for 29 data elements were compared to the corresponding data entered in the Ontario birth Registry using percent agreement, kappa statistics for categorical data elements and intra-class correlation coefficients (ICCs) for continuous data elements. RESULTS: Agreement ranged from 56.9 to 99.8%, but 76% of the data elements (22 of 29) had greater than 90% agreement. There was almost perfect (kappa 0.81-0.99) or substantial (kappa 0.61-0.80) agreement for 12 of the categorical elements. Six elements showed fair-to-moderate agreement (kappa <0.60). We found moderate-to-excellent agreement for four continuous data elements (ICC >0.50). CONCLUSION: Overall, the data elements we evaluated in the birth Registry were found to have good agreement with data from the patients' charts. Data elements that showed moderate kappa or low ICC require further investigation.

Severe Maternal Morbidity in Canada: Temporal Trends and Regional Variations, 2003-2016.

OBJECTIVE: This study sought to quantify temporal trends and provincial and territorial variations in severe maternal morbidity (SMM) in Canada. METHODS: The study used data on all hospital deliveries in Canada (excluding Québec) from 2003 to 2016 to examine temporal trends and from 2012 to 2016 to study regional variations. SMM was identified using diagnosis and intervention codes. Contrasts among periods and regions were quantified using rate ratios (RRs) and 95% confidence intervals (CIs). Temporal changes were also assessed using chi-square tests for trend (Canadian Task Force Classification II-1). RESULTS: The study population included 3 882 790 deliveries between 2003 and 2016 and 1 418 545 deliveries between 2012 and 2016. Severe hemorrhage rates increased from 44.8 in 2003 to 62.4 per 10 000 deliveries in 2012 (P for trend <0.0001) and then declined to 41.8 per 10 000 deliveries in 2016 (P for trend <0.0001). Maternal intensive care unit admission and sepsis rates decreased between 2003 and 2016, whereas rates of stroke, severe uterine rupture, hysterectomy, obstetric embolism, shock, and assisted ventilation increased. Rates of composite SMM in 2012-2016 were higher in Newfoundland and Labrador (RR 1.15; 95% CI 1.04-1.26), Nova Scotia (RR 1.11; 95% CI 1.03-1.19), New Brunswick (RR1.22; 95% CI 1.13-1.32), Manitoba (RR 1.09; 95% CI 1.03-1.15), Saskatchewan (RR 1.15; 95% CI 1.09-1.22), the Yukon (RR 1.74; 95% CI 1.35-2.25), and Nunavut (RR 1.76; 95% CI 1.46-2.11) compared with the rest of Canada, whereas rates were lower in Alberta and British Columbia. CONCLUSION: This surveillance report helps inform clinical practice and public health policy for improving maternal health in Canada.

Home birth integration into the health care systems of eleven international jurisdictions.

BACKGROUND: The purpose of this study was to develop assessment criteria that could be used to examine the level of integration of home birth within larger health care systems in developed countries across 11 international jurisdictions. METHODS: An expert panel developed criteria and a definition to assess home birth integration within health care systems. We selected jurisdictions based on the publications that were eligible for inclusion in our systematic review and meta-analysis on planned place of birth. We sent the authors of the included publications a questionnaire about home birth practitioners and practices in their respective health care system at the time of their studies. We searched published peer-reviewed, non-peer-reviewed, and gray literature, and the websites of professional bodies to document information about home birth integration in each jurisdiction based on our criteria. Where information was lacking, we contacted experts in the field from the relevant jurisdiction. RESULTS: Home birth is well integrated into the health care system in British Columbia (Canada), England, Iceland, the Netherlands, New Zealand, Ontario (Canada), and Washington State (USA). Home birth is less well integrated into the health care system in Australia, Japan, Norway, and Sweden. CONCLUSIONS: This paper is the first to propose criteria for the evaluation of home birth integration within larger maternity care systems. Application of these criteria across 11 international jurisdictions indicates differences in the recognition and training of home birth practitioners, in access to hospital facilities, and in the supplies and equipment available at home births, which give rise to variation in the level of integration across different settings. Standardized criteria for the evaluation of systems integration are essential for interpreting planned home birth outcomes that emerge from contextual differences.

Contribution of prepregnancy body mass index and gestational weight gain to adverse neonatal outcomes: population attributable fractions for Canada.

BACKGROUND: Low or high prepregnancy body mass index (BMI) and inadequate or excess gestational weight gain (GWG) are associated with adverse neonatal outcomes. This study estimates the contribution of these risk factors to preterm births (PTBs), small-for-gestational age (SGA) and large-for-gestational age (LGA) births in Canada compared to the contribution of prenatal smoking, a recognized perinatal risk factor. METHODS: We analyzed data from the Canadian Maternity Experiences Survey. A sample of 5,930 women who had a singleton live birth in 2005-2006 was weighted to a nationally representative population of 71,200 women. From adjusted odds ratios, we calculated population attributable fractions to estimate the contribution of BMI, GWG and prenatal smoking to PTB, SGA and LGA infants overall and across four obstetric groups. RESULTS: Overall, 6% of women were underweight (<18.5 kg/m(2)) and 34.4% were overweight or obese (≥25.0 kg/m(2)). More than half (59.4%) gained above the recommended weight for their BMI, 18.6% gained less than the recommended weight and 10.4% smoked prenatally. Excess GWG contributed more to adverse outcomes than BMI, contributing to 18.2% of PTB and 15.9% of LGA. Although the distribution of BMI and GWG was similar across obstetric groups, their impact was greater among primigravid women and multigravid women without a previous PTB or pregnancy loss. The contributions of BMI and GWG to PTB and SGA exceeded that of prenatal smoking. CONCLUSIONS: Maternal weight, and GWG in particular, contributes significantly to the occurrence of adverse neonatal outcomes in Canada. Indeed, this contribution exceeds that of prenatal smoking for PTB and SGA, highlighting its public health importance.

Contribution of prepregnancy body mass index and gestational weight gain to caesarean birth in Canada.

BACKGROUND: Overweight and obese women are known to be at increased risk of caesarean birth. This study estimates the contribution of prepregnancy body mass index (BMI) and gestational weight gain (GWG) to caesarean births in Canada. METHODS: We analyzed data from women in the Canadian Maternity Experiences Survey who had a singleton term live birth in 2005-2006. Adjusted odds ratios for caesarean birth across BMI and GWG groups were derived, separately for nulliparous women and parous women with and without a prior caesarean. Population attributable fractions of caesarean births associated with above normal BMI and excess GWG were calculated. RESULTS: The overall caesarean birth rate was 25.7%. Among nulliparous and parous women without a previous caesarean birth, rates in obese women were 45.1% and 9.7% respectively, and rates in women who gained above their recommended GWG were 33.5% and 8.0% respectively. Caesarean birth was more strongly associated with BMI than with GWG. However, due to the high prevalence of excess GWG (48.8%), the proportion of caesareans associated with above normal BMI and excess GWG was similar [10.1% (95% CI: 9.9-10.2) and 10.9% (95% CI: 10.7-11.1) respectively]. Overall, one in five (20.2%, 95% CI: 20.0-20.4) caesarean births was associated with above normal BMI or excess GWG. CONCLUSIONS: Overweight and obese BMI and above recommended GWG are significantly associated with caesarean birth in singleton term pregnancies in Canada. Strategies to reduce caesarean births must include measures to prevent overweight and obese BMI prior to conception and promote recommended weight gain throughout pregnancy.

Outcomes associated with planned place of birth among low-risk pregnancies in Ontario, Canada (2012-2021): A protocol for a population-based propensity score weighted cohort study.

BACKGROUND: Evidence suggests that for low-risk pregnancies, planned home births attended by a skilled health professional in settings where such services are well integrated are associated with lower risk of intrapartum interventions and no increase in adverse health outcomes. Monitoring and updating evidence on the safety of planned home births is necessary to inform ongoing clinical and policy decisions. METHODS: This protocol describes a population-based retrospective cohort study which aims to compare risk of (a) neonatal morbidity and mortality, and (b) maternal outcomes and birth interventions, between people at low obstetrical risk with a planned home birth with a midwife, a planned a hospital birth with a midwife, or a planned hospital birth with a physician. The study population will include Ontario residents who gave birth in Ontario, Canada between April 1, 2012, and March 31, 2021. We will use data collected prospectively in a provincial perinatal data registry. The primary outcome will be severe neonatal morbidity or mortality, a composite binary outcome that includes one or more of the following conditions: stillbirth during the intrapartum period, neonatal death (death of a liveborn infant in the first 28 completed days of life), five-minute Apgar score <4, or infant resuscitation requiring cardiac compressions. We will conduct a stratified analysis with three strata: nulliparous, parous-no previous caesarean birth, and parous-prior caesarean birth. To reduce the impact of selection bias in estimating the effect of planned place of birth on neonatal and maternal outcomes, we will use propensity score (PS) overlap weighting (OW) and modified Poisson regression to conduct multivariate analyses.