Defining a low-risk birth cohort: a cohort study comparing two perinatal data sets in Ontario, Canada.

Introduction: There are two main data sources for perinatal data in Ontario, Canada: the BORN BIS and CIHI-DAD. Such databases are used for perinatal health surveillance and research, and to guide health care related decisions. Objectives: Our primary objective was to examine the level of agreement between the BIS and CIHI-DAD. Our secondary objectives were to identify the differences between the data sources when identifying a low-risk birth (LRB) cohort and to understand their implications. Methods: We conducted a population-based cohort study comparing characteristics and clinical outcomes of all linkable births in BIS and CIHI-DAD between 1st April 2012 and 31st March 2018. We excluded out-of-hospital births, those with invalid healthcare numbers, non-Ontario residents and gestational age <20 weeks. We compared the portion of the cohort that met the criteria of a provincial definition of LRB based on each data source and compared clinical outcomes between the groups. Results: During the study period, 779,979 eligible births were linkable between the two data sources. After applying the LRB exclusions, there were 129,908 cases in the BIS and 136,184 cases in CIHI-DAD. Most exclusion criteria had almost perfect, substantial or moderate agreement. The agreement for non-cephalic presentation and BMI ≥ 40 kg/m2 (kappa coefficients 0.409 and 0.256, respectively) was fair. Comparison between the two LRB cohorts identified differences in the prevalence of cesarean (14.3% BIS versus 12.0% CIHI-DAD) and NICU admission (8.7% BIS versus 7.5% CIHI-DAD) and only 0.01% difference in the prevalence of ICU admission. Conclusions: Overall, we found high levels of agreement between the BIS and CIHI-DAD. Identifying a LRB cohort in either database may be appropriate, with the caveat of appropriate understanding of the collection, coding and definition of certain outcomes. The decision for selecting a database may depend on which variables are most important in a particular analysis.

The Effect of Prenatal Care Delivery Models Targeting Populations with Low Rates of PNC Attendance: A Systematic Review.

People at higher risk of poverty or social exclusion are less likely to receive adequate prenatal care (PNC) and have a higher risk of poor perinatal outcomes. Appropriate PNC may help to reduce adverse outcomes. We conducted a systematic review of randomized controlled trials in high income countries on the impact of PNC delivery models targeting populations with low rates of PNC attendance on maternal and newborn outcomes. Searches in four scientific databases identified seven eligible studies. Interventions included group PNC and augmented PNC. The quality of the evidence was moderate to very low. We found insufficient evidence to conclude whether or not these interventions can reduce rates of PTB and SGA. We conclude there is limited high quality evidence regarding the effectiveness of PNC delivery models targeting populations with low rates of PNC attendance and more high-quality research on promising interventions such as mobile PNC clinics is needed.

Outcomes of uninsured midwifery clients in Ontario, Canada: A retrospective cohort study.

OBJECTIVE: To describe the characteristics, health service utilization, and clinical outcomes of Ontario residents who are not covered by the Ontario Health Insurance Plan and receive services from Ontario midwives. DESIGN: Retrospective cohort study. SETTING: Ontario, Canada. PARTICIPANTS: All midwifery courses of care resulting in births between April 1, 2012 to March 31, 2015 and captured in the BORN perinatal registry. Within this cohort we compared midwifery clients without publicly funded health insurance to those covered by the Ontario Health Insurance Plan (OHIP). MEASUREMENTS AND FINDINGS: Of 55, 634 midwifery clients assessed in Ontario, 92.8% were insured by OHIP and 7.2% were not insured. Among uninsured clients, 66.3% attended a prenatal visit during the first trimester compared to 92.8% of insured women, with uninsured clients presenting with fewer pre-existing conditions. A higher proportion of uninsured clients (33.9%) planned to birth at home and 28.7% of clients' actual place birth was in the home, compared to 19.6% and 16.6% of insured clients respectively. Rates of both spontaneous labour and spontaneous vaginal birth were higher among uninsured clients (82.1% and 81.1%, respectively), compared to insured clients (77.3% and 78.1%, respectively). Clinical outcomes were generally similar, with postpartum hemorrhage (3.4%), preterm birth (5%), and small-for-gestational age (2.1%) slightly more common among uninsured clients compared to insured clients (2.9%, 4.4%, and 1.7%, respectively). Rates of most complications were lower for uninsured clients. KEY CONCLUSIONS: Overall, uninsured clients used less services compared to insured clients and had good clinical outcomes under midwifery care in Ontario. Findings of this study support the policy decision in Ontario to fund midwifery care for uninsured clients and suggest that uninsured clients are well suited for midwifery care. IMPLICATIONS FOR PRACTICE: Funding midwives to serve uninsured clients is appropriate and may improve uninsured clients access to care.

Perceptions of barriers to accessing perinatal mental health care in midwifery: A scoping review.

BACKGROUND: Despite greater contact with the healthcare system during the perinatal period, detection and treatment of perinatal mental health conditions remain suboptimal. AIM: To explore midwives' and midwifery clients' perceptions of factors that impede access to perinatal mental health care in high resource settings. DESIGN: Scoping review. METHODS: Arksey and O'Malley's (2006) framework for scoping studies was employed. A systematic search of the literature was completed. Included publications must have (1) addressed barriers to obtaining perinatal mental health care; (2) been either peer-reviewed primary literature or grey literature; (3) if primary literature, the study explored the perceptions of midwives or those in midwifery care; and (4) if grey literature, the publication pertained directly to midwifery care. A study was excluded from the review if (1) it was published in a language other than English; (2) it was published prior to the year 2000; or (3) it took place in a country with a Maternal Mortality Ratio (MMR) above 14. Identified barriers were mapped onto Levesque et al.'s (2013) ten-dimension framework (five supply-side dimensions and five demand-side dimensions) on access to health care in order to determine which points along the chain to accessing perinatal mental health care were most adversely impacted. FINDINGS: The search yielded a total of 1051 records, and twenty-six were included in the review (qualitative, quantitative, mixed methods, grey literature). Supply-side barriers included midwives' lack of PMH training, knowledge, and confidence, both generally and cross-culturally; inconsistent screening practices; broken referral pathways; lack of specialized services; underlying stigma toward those with PMH concerns; inefficiently long wait lists for services; and midwives' perception that PMH is not within their scope of practice. Demand-side barriers included emotional isolation and loneliness; normalization of PMH concerns as symptoms of pregnancy; cultural norms surrounding motherhood and mental health; and symptoms of PMH concerns as inhibiting the ability to obtain help. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Twenty-one out of the twenty-six publications included in this review identified problems at the very beginning of the care-accessing process, suggesting that PMH care is often unapproachable, or that people are unable to perceive their need for care in the first place. Midwives can help ameliorate these initial barriers by engaging in additional perinatal mental health training in order to increase knowledge and confidence; being aware of community resources and referral pathways; and initiating discussion about perinatal mental health with all clients with the help of a validated screening tool.

Barriers and facilitators of accessing perinatal mental health services: The perspectives of women receiving continuity of care midwifery.

OBJECTIVE: To explore what factors midwifery care recipients perceive to prevent or facilitate access to mental health care in the perinatal period. DESIGN: A qualitative descriptive study based on semi-structured individual interviews and focus groups. SETTING: Ottawa, Ontario, Canada. PARTICIPANTS: Sixteen mothers who had received or were currently receiving midwifery care. Eligibility criteria were being 18 or older and self-identifying as having experienced or experiencing perinatal mental health concerns. FINDINGS: Five salient themes emerged from the data: cultural values, knowledge, relationships, flexibility, and system gaps. Barriers and facilitators to accessing perinatal mental health services are grouped under each theme. Stigma and fear, broken referral pathways, distant service location, lack of number/capacity of specialised services, baby-centredness, discharge from midwifery care at six weeks postpartum, and cost were barriers to accessing care. Information and midwives' knowledge/experience were context-specific factors that could hinder or facilitate access. Continuity, community, and advocacy were facilitators to accessing care. Many of these facilitators are an inherent part of the Ontario midwifery model of care. Conversely, some aspects of midwives' scope of practice in Ontario impeded access to perinatal mental health care, including inability to make direct referrals to psychiatrists and discharge from care at six weeks postpartum. KEY CONCLUSION: Midwifery care based on the principles of continuity of care, woman-centred care, informed choice, and advocacy may help to enhance the uptake of perinatal mental health care, but access to such care also remains dependent on the characteristics of mental health services themselves. IMPLICATIONS FOR PRACTICE: Midwives can enhance access to perinatal mental health services by developing relationships that create safe conditions for disclosure; providing information about symptoms of perinatal mental health concerns, treatment, and services to clients and their social support network; being knowledgeable about existing resources and referral pathways; and identifying when women need additional support to seek care and facilitating connections to available services.

Association of Universal Bilirubin Screening With Socioeconomic Disparities in Newborn Follow-up.

OBJECTIVE: To determine whether implementation of universal bilirubin screening in Ontario, Canada is associated with improved rates of recommended follow-up care across socioeconomic status (SES). METHODS: We conducted a retrospective population-based cohort study of all babies born at ≥35 weeks' gestation and discharged to home within 72 hours from 97 hospitals between April, 2003 and February, 2011. We used linked administrative health data sets to measure recommended follow-up care (physician visit within 1 day of discharge for babies discharged ≤24 hours after birth, or physician visit within 2 days for babies discharged 24-72 hours after birth). We used maternal postal code and the Canadian Deprivation Index to determine material deprivation quintile. We modeled the relationship between universal bilirubin screening and outcomes using generalized estimating equations to account for clustering according to hospital, underlying temporal trends, and important covariates. RESULTS: Universal bilirubin screening was associated with a modest increase in recommended follow-up from 29.9% to 35.0% (n = 711,242; adjusted relative risk: 1.11; P = .047). Disparity in recommended follow-up increased after screening implementation, with 40% of the crude increase attributable to the highest SES quintile and none to the lowest SES quintile. CONCLUSIONS: Universal bilirubin screening has had only a modest effect in ensuring timely follow-up for Ontario newborn babies, which represents an ongoing weakness in efforts to prevent severe hyperbilirubinemia. The observed increase in SES disparity in access to recommended follow-up suggests that universal programs that fail to address root causes of disparities might lead to overall improvements in population outcomes but increased inequity.

Universal bilirubin screening and health care utilization.

OBJECTIVE: To evaluate the impact of the implementation of universal bilirubin screening on neonatal health care use in the context of a large jurisdiction with universal health insurance. METHODS: We conducted a population-based retrospective cohort study of all newborns discharged after birth between April 2003 and February 2011 from 42 hospitals that implemented universal bilirubin screening between July 2007 and June 2010 in Ontario, Canada. We surveyed hospitals to determine their screening implementation date. We used multiple linked administrative health data sets to measure phototherapy use, length of stay (LOS), jaundice-related emergency department visits, and jaundice-related readmissions. We modeled the relationship between universal bilirubin screening and outcomes using generalized estimating equations to account for clustering by hospital, underlying temporal trends, and important covariates. RESULTS: Screening was associated with an increase in phototherapy during hospitalization at birth (relative risk, 1.32; 95% confidence interval, 1.09-1.59) and a decrease in jaundice-related emergency department visits (relative risk, 0.79; 95% confidence interval, 0.64-0.96) but no statistically significant difference in phototherapy after discharge, LOS, or jaundice-related readmissions after accounting for preexisting temporal trends in health care service use and other patient sociodemographic and hospital characteristics. CONCLUSIONS: Universal bilirubin screening may not be associated with increased neonatal LOS or increased subsequent hospital use. Our findings are relevant for determining the resource implications of universal bilirubin screening in Ontario. They highlight the limitations in generalizability of previous research on health care utilization associated with similar programs and underline the importance of context-specific local evaluation of guideline implementation.

Implementation of the Canadian Paediatric Society's hyperbilirubinemia guidelines: A survey of Ontario hospitals.

INTRODUCTION: In 2007, the Canadian Paediatric Society (CPS) published guidelines aimed at preventing severe hyperbilirubinemia. OBJECTIVES: To determine whether hospitals had implemented these guidelines; to investigate how guideline-recommended care is organized; and to understand the factors influencing guideline implementation. METHODS: The present study was an online survey conducted from December 2011 to May 2012 of all Ontario hospitals offering maternal-newborn services. RESULTS: A total of 97 of 100 eligible hospitals responded. Seventy-seven of the 97 (79%) respondents reported having implemented universal neonatal bilirubin screening. Among these hospitals, hospital-based postdischarge follow-up was reported more frequently than follow-up at community-based locations: hospital laboratory (n=40 [52%]), mother-baby care unit (n=32 [42%]), outpatient clinic (n=25 [33%]), primary care provider in community (n=19 [25%]) and community laboratory (n=8 [10%]). The CPS guidelines were the most frequently reported factor influencing implementation (n=74 [96%]). DISCUSSION: The survey provides valuable insight into the impact of a complex guideline in Canada's largest province. There was heterogeneity in how hospitals organized services, but there was a notable trend toward hospital-based postdischarge care. The shift to hospital-based care runs counter to current health policy directions and highlights the lack of integration among health care sectors. CONCLUSION: The majority of Ontario hospitals implemented universal bilirubin screening following the release of the CPS guidelines. Further analysis is needed to determine the impact that the guidelines and the differences in implementation have had on clinical outcomes and the utilization of health services.

INTRODUCTION: En 2007, la Société canadienne de pédiatrie (SCP) a publié des lignes directrices afin de prévenir l'hyperbilirubinémie grave. OBJECTIFS: Déterminer si les hôpitaux ont adopté ces lignes directrices, examiner l'organisation des soins recommandée dans les lignes directrices et comprendre les facteurs qui influent sur la mise en œuvre des lignes directrices. MÉTHODOLOGIE: La présente étude rend compte d'une enquête virtuelle menée de décembre 2011 à mai 2012 auprès de tous les hôpitaux ontariens offrant des services mère-enfant. RÉSULTATS: Au total, 97 des 100 hôpitaux admissibles ont répondu à l'enquête. Soixante-dix-sept des 97 répondants (79 %) ont déclaré avoir adopté le dépistage universel de la bilirubine néonatale. Dans ces hôpitaux, le suivi en milieu hospitalier après le congé était plus fréquent que le suivi en milieu communautaire : laboratoire de l'hôpital (n=40 [52 %]), unité de soins mère-enfant (n=32 [42 %]), consultations externes (n=25 [33 %]), dispensateur de soins de première ligne en milieu communautaire (n=19 [25 %]) et laboratoire en milieu communautaire (n=8 [10 %]). Les lignes directrices de la SCP étaient le plus souvent invoquées comme le facteur ayant suscité cette mise en œuvre (n=74 [96 %]). EXPOSÉ: L'enquête donne un aperçu précieux des répercussions de lignes directrices complexes dans la plus grande province canadienne. On a remarqué une organisation hétérogène des services dans les hôpitaux, mais une tendance nette vers des soins en milieu hospitalier après le congé. Le passage à des soins en milieu hospitalier va à l'encontre des directives de santé actuelles et fait ressortir l'absence d'intégration entre les secteurs de soins. CONCLUSION: La majorité des hôpitaux ontariens a adopté le dépistage universel de la bilirubine après la publication des lignes directrices de la SCP. Il faudra effectuer une analyse plus approfondie pour déterminer les répercussions de ces lignes directrices et des divers modes de mise en œuvre sur les résultats cliniques et l'utilisation des services de santé.