Perinatal Health Report 2009â€“2010

August 2011

Perinatal Health Report 2009–2010

Greater Toronto Area — LHINs 5 to 9

BORN Ontario Perinatal Health Report 2009–2010 – Greater Toronto Area (GTA) LHIN Region 1

Dear Colleagues: The Better Outcomes Registry & Network (BORN) Ontario is pleased to release this series of reports that provide an overview of the 2009–2010 fiscal year maternal‐newborn outcomes for hospitals within Local Health Integration Networks (LHINs) in Ontario. There are five reports of combined LHINs corresponding to perinatal regions in Ontario. In September 2010, a companion series of seven reports for public health regions in Ontario was distributed. We hope you find this report informative and useful for guiding policy decisions for maternal and newborn issues in your region. Please share this report and use it to guide discussions with colleagues about how to improve programs or learn from others about best practices. Please feel free to provide BORN Ontario with any feedback about how this report could be improved or suggestions for further targeted reports to enhance understanding of particular issues.

Although significant effort has been made to ensure the accuracy of the information presented in this report, neither the authors nor BORN Ontario nor any other parties make any representation or warranties as to the accuracy, reliability or completeness of the information contained herein. The information in this report is not a substitute for clinical judgment or advice. Permission is granted for the reproduction of these materials solely for non‐commercial and educational purposes. Suggested citation: Better Outcomes Registry & Network (BORN) Ontario. Perinatal Health Report 2009–2010. Greater Toronto Area (GTA) – LHINs 5 to 9. Ottawa ON, 2011.


TABLE OF CONTENTS List of Figures ……………………………………………………………………………………………………............ 4 Preface ………………………………………………………………………………………………………………………… 8 Acknowledgements ……………………………………………………………………………………………………… 9 About the Better Outcomes Registry & Network (BORN Ontario) ………………………………… 10 Executive Summary ……………………………………………………………………………………………………… 11 Introduction ………………………………………………………………………………………………………………... 14 Methods ………………………………………………………………………………………………………………………. 15

Chapter 1 Profile of Greater Toronto Area LHIN Region and Obstetrical Population Introduction …………………………………………………………………………………………... 19 Choice of birthplace ……………………………………………………………………………….. 29 Maternal Age ………………………………………………………………………………………….. 31

Chapter 2 Pregnancy ………………………………………………………………………………………………. 39 Chapter 3 Maternity Health Service Issues Level of Care …………………………………………………………………………………………… 45 Maternal Inter‐hospital Transfers …………………………………………………………… 50 Chapter 4 Birth

Type of Care Provider at Delivery …………………………………………………………... 54 Fetal Surveillance …………………………………………………………………………………… 56 Induction of Labour ……………………………………………………………………………….. 60 Type of Delivery ……………………………………………………………………………………… 67 Elective Repeat Cesarean Delivery ………………………………………………………… 76 Pain Management in Labour and Birth …………………………………………………… 81 Fetal Mortality …………………………….………………………………………………………… 89 Preterm Birth ………………………………………………………………………………………… 90 Fetal Growth – Small for Gestational Age and Large for Gestational Age 95 Multiple Birth ………………………………………………………………………………………… 99

Chapter 5 Postpartum and Newborn ……………………………………………………………………… 106 Breastfeeding ………………………………………………………………………………………… 110 Chapter 6 Maternal and Newborn Screening ………………………………………………………….. 114


APPENDICES A BORN Ontario Contact Information ………………………………………………………………….... 121 B Accessing BORN Ontario Data …………………………………………………………………………….. 122 C Number of total hospital births, by hospital site and fiscal year, Greater Toronto

Area (GTA) LHIN Region, 2005–2006 to 2009–2010 …………………………………………. 123 D Maternal pre‐existing health condition categories in BORN–Niday Perinatal Database 125 E Obstetrical complication categories in BORN–Niday Perinatal Database ……………… 126 F Hospital sites and level of care, Greater Toronto Area (GTA) LHIN Region …………… 128 G Distribution of live births at each level of care, by gestational age at birth and fiscal year, Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010 ……….. 130 H Intrapartum complication categories in BORN–Niday Perinatal Database ……………. 131


LIST OF FIGURES Chapter 1 Profile of Greater Toronto Area (GTA) LHIN Region and Obstetrical Population Figure 1.1 Number of women who gave birth, by LHIN of birth and fiscal year, Greater Toronto Area

(GTA) LHIN Region, 2005–2006 to 2009–2010 Figure 1.2 Number of women who gave birth, by LHIN of maternal residence and fiscal year, Greater

Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010 Figure 1.3 Number of total births, by LHIN of birth and fiscal year, Greater Toronto Area (GTA) LHIN

Region, 2005–2006 to 2009–2010 Figure 1.4 Number of total births, by LHIN of maternal residence and fiscal year, Greater Toronto

Area (GTA) LHIN Region, 2005–2006 to 2009–2010 Figure 1.5a Distribution of LHIN of maternal residence among women who had a hospital birth in the

GTA, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010 Figure 1.5b Proportion of women who had a hospital birth in their LHIN of residence, by LHIN of birth,

Greater Toronto Area (GTA) LHIN Region, 2009–2010 Figure 1.6a Distribution of LHIN of hospitals among GTA residents who had a hospital birth, by LHIN of

maternal residence, Greater Toronto Area (GTA) LHIN Region, 2009–2010 Figure 1.6b Proportion of women who had a hospital birth in their LHIN of residence, by LHIN of

maternal residence, Greater Toronto Area (GTA) LHIN Region, 2009–2010 Figure 1.7 Number of women in midwifery care that gave birth at home, by LHIN of maternal

residence, Greater Toronto Area (GTA) LHIN Region, 2009–2010 Figure 1.8 Distribution of maternal age, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region,

2009–2010 Figure 1.9 Proportion of women who were <20 years at delivery, by fiscal year, Greater Toronto Area

(GTA) LHIN Region, 2005–2006 to 2009–2010 Figure 1.10 Proportion of women who were ≥35 years at delivery, by fiscal year, Greater Toronto Area

(GTA) LHIN Region, 2005–2006 to 2009–2010 Figure 1.11 Distribution of parity, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–

2010 Figure 1.12 Proportion of women who were ≥35 years and nulliparous at delivery, by LHIN of birth,

Greater Toronto Area (GTA) LHIN Region, 2009–2010 Figure 1.13 Proportion of women who were ≥35 years and nulliparous at delivery, by fiscal year,

Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010 Chapter 2 Pregnancy Figure 2.1 Proportion of women who did not attend an antenatal visit with a health care provider

during the first trimester, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 2.2

Proportion of women with pre‐existing health conditions, by fiscal year, Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010

Figure 2.3

Proportion of women with obstetrical complications during pregnancy, by fiscal year, Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010

Figure 2.4 Rate of assisted conception, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010


Chapter 3 Maternity Health Service Issues Figure 3.1 Distribution of live births at each level of care, by LHIN of birth, Greater Toronto Area

(GTA) LHIN Region, 2009–2010 Figure 3.2 Distribution of live births at each level of care, by gestational age at birth, Greater Toronto

Area (GTA) LHIN Region, 2009–2010 Figure 3.3 Distribution of live births 24–36 weeks at each level of care, by gestational age at birth

and fiscal year, Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010 Figure 3.4 Inter‐hospital maternal transfer profile, by level of care of receiving hospital, Greater

Toronto Area (GTA) LHIN Region, 2009–2010 Figure 3.5 Proportion of maternal inter‐hospital transfers to a higher, equivalent or lower level of

care, by level of care of sending hospital, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Chapter 4 Birth Figure 4.1 Distribution of type of health care provider who attended the hospital birth, by LHIN of

birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 4.2 Fetal surveillance methods during labour, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 4.3 Rate of auscultation only for fetal surveillance during labour, by fiscal year, Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010

Figure 4.4 Distribution of type of labour, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 4.5 Rate of labour induction, by fiscal year, Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010

Figure 4.6 Rate of labour induction, by hospital level of care, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 4.7 Proportion of women who underwent labour induction, by gestational age at birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 4.8 Indication for induction of labour, Greater Toronto Area (GTA) LHIN Region, 2009–2010 Figure 4.9 Proportion of women who were <41 weeks of gestational age at delivery among women

who were induced and had a post dates indication for induction of labour, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 4.10 Rate of operative vaginal delivery, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 4.11 Rate of operative vaginal delivery, by fiscal year, Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010

Figure 4.12 Rate of cesarean delivery, by fiscal year, Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010

Figure 4.13 Rate of cesarean delivery, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 4.14 Rate of cesarean delivery, by hospital level of care, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 4.15 Rate of cesarean delivery, by Robson classification groups, Greater Toronto Area (GTA) LHIN Region, 2005–2006 and 2009–2010

Figure 4.16 Proportion of women with a cesarean delivery performed prior to 39 weeks’ gestation among low‐risk women having an elective repeat cesarean delivery at term, by LHIN of


birth, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010 Figure 4.17 Rate of episiotomy or 3rd/4th degree perineal laceration, by LHIN of birth, Greater

Toronto Area (GTA) LHIN Region, 2009–2010 Figure 4.18 Rate of episiotomy or 3rd/4th degree perineal laceration, by fiscal year, Greater Toronto

Area (GTA) LHIN Region, 2005–2006 to 2009–2010 Figure 4.19 Proportion of women with intrapartum complications, by fiscal year, Greater Toronto

Area (GTA) LHIN Region, 2005–2006 to 2009–2010 Figure 4.20 Rates of pharmacologic pain management among women who had a vaginal live birth,

by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010 Figure 4.21 Rates of pharmacologic pain management among women who had a vaginal live birth,

by fiscal year, Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010 Figure 4.22 Rates of pharmacologic pain management among women who had a vaginal live birth,

by hospital level of care, Greater Toronto Area (GTA) LHIN Region, 2009–2010 Figure 4.23 Rates of pharmacologic pain management among women who had a cesarean live birth,

by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010 Figure 4.24 Rates of pharmacologic pain management among women who had a cesarean live birth,

by fiscal year, Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010 Figure 4.25 Rates of pharmacologic pain management among women who had a cesarean live birth,

by hospital level of care, Greater Toronto Area (GTA) LHIN Region, 2009–2010 Figure 4.26 Length of second stage of labour among women with a vaginal birth, by parity, Greater

Toronto Area (GTA) LHIN Region, 2009–2010 Figure 4.27 Fetal mortality rate ≥500 grams, by LHIN of birth, Greater Toronto Area (GTA) LHIN

Region, 2009–2010 Figure 4.28 Rate of preterm birth, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–

2010 Figure 4.29 Rate of preterm birth, by fiscal year, Greater Toronto Area (GTA) LHIN Region, 2005–

2006 to 2009–2010 Figure 4.30 Rate of preterm birth, by hospital level of care, Greater Toronto Area (GTA) LHIN Region,

2009–2010 Figure 4.31 Rate of preterm birth, by plurality and fiscal year, Greater Toronto Area (GTA) LHIN

Region, 2005–2006 to 2009–2010 Figure 4.32 Rate of small for gestational age, by LHIN of birth, Greater Toronto Area (GTA) LHIN

Region, 2009–2010 Figure 4.33 Rate of large for gestational age, by LHIN of birth, Greater Toronto Area (GTA) LHIN

Region, 2009–2010 Figure 4.34 Rate of small for gestational age and large for gestational age, by fiscal year, Greater

Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010 Figure 4.35 Rate of multiple birth, by fiscal year, Greater Toronto Area (GTA) LHIN Region, 2005–

2006 to 2009–2010 Figure 4.36 Rate of multiple birth, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–

2010 Chapter 5 Postpartum and Newborn Figure 5.1 Proportion of live births with a 5‐minute Apgar score below 4 or between 4 and 6, by

LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 5.2 Proportion of live births with a 5‐minute Apgar score below 4 or between 4 and 6, by hospital level of care, Greater Toronto Area (GTA) LHIN Region, 2009–2010


Figure 5.3 Proportion of live births requiring resuscitation, by gestational age, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 5.4 Proportion of live births with birth depression, by gestational age, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 5.5 Rate of exclusive breastfeeding at discharge among term live births, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Chapter 6 Maternal and Newborn Screening Figure 6.1 Ratio of maternal multiple marker screening, by LHIN of residence, Greater Toronto

Area (GTA) LHIN Region, 2009–2010

Figure 6.2 Proportion of women who were screened for Group B Streptococcus among women who delivered at ≥37 weeks of gestation, by LHIN of birth, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 6.3 Number of infants with newborn screening completed and proportion who screen positive, by LHIN of residence, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 6.4 Ratio of Parkyn screen completion, by LHIN of residence, Greater Toronto Area (GTA) LHIN Region, 2009–2010

Figure 6.5 Proportion of infants who received a Parkyn screen score of nine or greater, by LHIN of residence, Greater Toronto Area (GTA) LHIN Region, 2009–2010


Preface The Better Outcomes Registry & Network (BORN) Ontario (formerly the Ontario Perinatal Surveillance System) is pleased to present this Perinatal Health Report for hospitals within Local Health Integration Networks (LHINs) 5 to 9 for the Greater Toronto Area (GTA). It provides data on maternal and newborn health and outcomes of interest to maternal‐newborn care providers, administrators, LHIN personnel, government and families in Ontario, for the 2009–2010 fiscal year, and with 5‐year trends where possible. The content and presentation of this report by BORN Ontario differs from previous reports by the Ontario Perinatal Surveillance System in a number of ways. For the first time, we are reporting data by combined LHIN regions for the entire province. Some data are presented for individual LHINs within the region and others focus on the region itself, particularly when numbers are small. In response to input received from hospital care providers, BORN has added a number of new figures to this report, has included definitions for all of the indicators, and has provided additional background information and data interpretation. We greatly appreciate the on‐going support of our hospital and regional network colleagues for their assistance and input into the content of these reports. Quality perinatal health care requires that hospitals work in partnership with colleagues in public health and community agencies. The continuum of care during pregnancy and birth takes women and families from home to offices, clinics, and hospitals, with return for follow‐up care to these community settings after the birth. Our hope in providing these data is that they will be used by those providing care in public health, community and acute care settings to stimulate discussions and partnerships to solve common maternal and newborn care issues. We also encourage you to use these data to facilitate program management, benchmarking, quality improvement initiatives, planning, evaluation and research. Suggestions for future reports can be directed to any member of the BORN team (see APPENDIX A for contact information) or to Ann Sprague, Scientific Manager of BORN Ontario ([email protected]).


Acknowledgements BORN Ontario would like to acknowledge the tremendous work of the hospital personnel and regional maternal/newborn programs we consulted in developing content for this report. We particularly appreciate the guidance of the former Child Health Network (CHN) in Toronto and the former Perinatal Partnership Program of Eastern and Southeastern Ontario (PPPESO) who had previously produced regional reports. As we plan for future reports, we are especially interested in hearing from Northern LHINs, smaller hospitals and other regional networks with respect to indicators that are of particular relevance to them. We appreciate the guidance provided by the Scientific Working Group of BORN Ontario and thank them for their contribution. We also thank BORN Ontario partners who contributed data for this report – Jennifer Milburn from Newborn Screening Ontario, Tianhua Huang from the Ontario Maternal Multiple Marker Screening Program, Seetha Raja from the Ontario Midwifery Program, Vivian Holmberg on behalf of the Ontario Midwifery Program and Alex Rishea who provided data from the Ontario Ministry of Children and Youth Services. Special thanks to Brittan Fell and David King of BORN Ontario who provided help with lay‐out for the report, and Karine Tawagi and Yanfang Guo who helped produce graphs. The individuals who produced the content and/or advised on the development of this report or provided review and feedback include: Principal Authors

Deshayne Fell Epidemiologist, BORN Ontario

Monica Prince Data Analyst, BORN Ontario

Ann Sprague Scientific Manager, BORN Ontario

Mark Walker Scientific Director, BORN Ontario

Section Authors

Liz Darling

Midwife & PhD Candidate, University of Ottawa; Research Fellowship, Ottawa Hospital Research Institute

Sandra Dunn Perinatal Consultant, Champlain Maternal Newborn Regional Program

Reviewers and Contributors

Diane Belanger‐Gardner

Administrative Director, Family Child Program, Hôpital Régional de Sudbury Regional Hospital

Tammy Budhwa Regional Coordinator, BORN Ontario

Barbara Chapman Data Quality Management Specialist, BORN Ontario

Glenda Hicks Regional Coordinator, BORN Ontario

Vivian Holmberg Regional Coordinator, BORN Ontario


Sally Jenkins

Interim Program Director Women & Children's Health, Chatham Kent Health Alliance

Susan Jewell Regional Coordinator, BORN Ontario

Sarah MacDonald

Maternal‐Fetal Medicine, McMaster University Medical Centre and McMaster University

Kelly Pearce Regional Coordinator, BORN Ontario

Monica Poole Regional Coordinator, BORN Ontario

Joel Ray Maternal‐Fetal Medicine, St. Michael’s Hospital and University of Toronto

Brian Schnarch Senior Epidemiologist, Champlain Local Health Integration Network

Graeme Smith

Maternal‐Fetal Medicine, Kingston General Hospital and Queen’s University; Chair, BORN Ontario – Maternal Newborn Outcomes Committee

About the Better Outcomes Registry & Network (BORN Ontario)

BORN Ontario (formerly the Ontario Perinatal Surveillance System) was funded in January of 2009 by the Ontario Ministry of Health and Long‐Term Care (MOHLTC). BORN Ontario would like to acknowledge the tremendous vision and support of the Ministry of Health and Long‐Term Care in helping us to meet our goals and progress towards our mission of being an authoritative and definitive source of accurate and timely information to monitor, evaluate and plan for the best possible beginnings for life‐long health.

BORN operates under the auspices of the Children’s Hospital of Eastern Ontario and is recognized (as of November 2009) as a registry of personal health information under the Ontario Personal Health Information Protection Act (PHIPA). The focus of BORN Ontario has been to work on:

Building capacity to enhance data quality, data output, research activities, and reporting.

Improving data capture to include all hospitals and midwifery practices. As of November 2009, all Ontario hospitals with maternal‐newborn services are contributing data.

Developing a new database to integrate data from the five founding partners – Ontario Maternal Multiple Marker Screening Database, Fetal Alert Network, Niday Perinatal and NICU/SCN Databases, Ontario Midwifery Program Database and Newborn Screening Ontario to permit future analysis, research and reporting across multiple touch points within the maternal‐newborn continuum of care.

Developing and submitting privacy and security policies and procedures for review by the Ontario Information and Privacy Commissioner, required by PHIPA registry status.

Communicating our mission, vision, and activities to all groups who will work with the organization as we move forward.

For those wishing to access BORN Ontario data for research or quality improvement projects, an outline of the process and guidelines can be found in APPENDIX B.


Executive Summary The purpose of this report is to provide an overview of maternal‐newborn indicators and trends for policy makers, hospitals, Local Health Integration Networks (LHINs) and clinicians providing maternity services. Greater Toronto Area (GTA) LHINs provide obstetrical services to more than half (52.7%) of Ontario residents who give birth in Ontario hospitals each year, thus effective and efficient delivery of obstetrical health services in the five LHINs that make up the GTA is extremely important. There are many factors that influence the demands on both general and highly specialized obstetrical and neonatal services. These include, but are not limited to, the background characteristics and health of the obstetrical population (such as maternal age and underlying medical co‐morbidities), risk factors (such as multifetal gestation and previous cesarean), obstetrical practices with regard to the use of intrapartum interventions (such as labour induction and primary or repeat cesarean delivery), and prevalence of adverse newborn outcomes (such as preterm birth, growth restriction, and birth depression). Some key findings from this report that directly relate to or strongly influence the delivery of obstetrical health services and quality care in the GTA are summarized here: Health services utilization:

Although the majority of women in the GTA give birth in the LHIN in which they reside, there is considerable mobility across LHIN boundaries. In particular, about 41% of women who give birth in the Toronto Central LHIN reside in another LHIN. There are a number of explanations that likely influence these care patterns, including availability of high‐risk obstetrical care services, geographic proximity to a hospital in a neighbouring LHIN, capacity issues, and maternal choice.

In 2009–2010, a total of 967 women in midwifery care gave birth at home.

There were a total of 412 maternal inter‐hospital transfers resulting in a delivery that occurred in a GTA hospital in 2009–2010, of which 73 (17.7%) were from a hospital outside of the GTA LHIN Region. Among the remaining 339 maternal transfers that occurred between GTA hospital sites, 262 (77.1%) were to a hospital with a higher level of care.

Awareness of patterns of health services utilization are essential for service planning to ensure that adequate resources are available and that the health care system supports appropriate access to services as close to home as possible.

Appropriateness:

The proportion of live births between 24–31 weeks of gestational age that were born outside a Level III hospital (the optimal level of care for this gestational age) increased between 2005–2006 and 2008–2009 from 32.5% to 42.6%. However, in 2009–2010, this trend showed evidence of change with the proportion of live births between 24–31 weeks born outside a Level III hospital decreasing to 33.2%.

Less than a quarter (21.3%) of infants born during a gestational period where survival is extremely low (<24 weeks’ gestation) were born at a Level III centre (26 out of 122 live births). The reasons why these infants are not reaching tertiary care are likely complex and include a ‘grey zone’ in terms of survival/long‐term outcome, parental wishes, and no clear clinical practice guidelines to guide care providers in a situation that can change almost daily.


Preterm infants born in hospitals equipped to deal with their complex needs have better outcomes than infants born outside these hospitals who require transport after birth, or who stay in hospitals with lower levels of neonatal care and support. Monitoring births at various levels of care is an important strategy to ensure adequate system resources and ultimately to improve patient safety and outcomes.

Population profile:

More than one in five women (25.4%) who gave birth in 2009–2010 in the GTA were 35 years of age or older. Between 2005–2006 and 2009–2010, the proportion of women giving birth in the GTA who were >35 years of age increased slightly, from 23.6% to 25.4%.

In 2009–2010, 24.8% of women had one or more pre‐existing health conditions and 24.3% had one or more obstetrical complications during their pregnancy.

In 2009–2010, the rate of preterm birth in the GTA LHIN Region was 8.1% and changed very little between 2005–2006 and 2009–2010. The corresponding number of babies born at <37 weeks of gestational age in 2009–2010 was 5,854.

Rates of small for gestational age (SGA) were very stable between 2005–2006 and 2009–2010 in the GTA. In 2009–2010, 10.5% of singleton live births were SGA.

The multiple birth rate in the GTA LHIN Region in 2009–2010 was 3.7%, corresponding to 2,739 infants. The rate of multiple birth was considerably higher in Toronto Central LHIN.

Having contemporary information on characteristics of the maternal‐newborn population and monitoring trends in these characteristics is important for system planning. With the distribution of age at the time of birth continuing to shift and complications associated with increasing age in pregnancy known, system planners and funders will need to project service needs.

Intrapartum interventions:

The rate of labour induction in the overall obstetrical population was 23.0% and in low‐risk nulliparous women was 30.6% in 2009–2010. The rate of labour induction in low‐risk nulliparous women increased between 2005–2006 and 2009–2010 (from 28.1% to 30.6%).

The rate of cesarean delivery among women with a term singleton who had given birth by cesarean in a previous pregnancy has increased and in 2009–2010, it made the largest contribution to the overall rate of cesarean delivery (29.4%). Reducing primary cesarean deliveries is one of the most important strategies for reducing the total cesarean rate. Following best practice guidelines for care during labour and initiating an audit and feedback mechanism to monitor practice patterns are important strategies for hospitals and regional programs.

Increases in intrapartum interventions have important implications, since they can affect service requirements and capacity issues.

Effectiveness:

In 2009–2010, 91.7% of women had electronic fetal monitoring (either alone or in combination with auscultation) at some time during their labour. The proportion of women who received auscultation only during labour was 6.5% in the overall obstetric population and 10.8% in low‐risk women. Given that clinical practice guidelines recommend auscultation as the primary method of surveillance in low‐risk women in labour, there is room for improvement. In the general population, high rates of


inductions and epidural analgesia lead care providers to use EFM. Clinical practice guidelines also support auscultation in low‐risk women undergoing epidural analgesia.

The proportion of elective repeat cesarean deliveries at term in low‐risk women not in labour performed prior to 39 weeks was 63.0% (6.4% at 37 weeks and 56.6% at 38 weeks) in the GTA, higher than the other regions of the province. There is clear evidence that this practice can lead to complications in the newborn and in the absence of medical or obstetrical indication, elective repeat cesarean deliveries should be delayed until at least 39 weeks.

Across the GTA in 2009–2010, 18.4% of women (1,079 out of 5,866 women) who were induced and had a documented indication of post‐dates pregnancy were <41 weeks of gestational age at the time they gave birth. This was particularly high in Central West (27.5%), Central (26.4%) and Central East (25.0%) LHINs.

58.9% of term live born babies were being exclusively breastfed at the time they were discharged from hospital. A further 30.9% of term infants were being supplemented at the time of discharge (i.e., they received a combination of breast milk and formula or other supplement). Breastfeeding support and supplementation rates need further investigation. [Note that breastfeeding rates for the GTA region are based on denominators that exclude a substantial proportion of their population of term live births due to incomplete collection of breastfeeding information in some hospital sites.]

A high proportion of women (94.7%) delivering at term were screened for Group B Streptococcus.

Best practice guidelines exist for the areas listed above and based on these findings, there are areas where improvement is needed. These examples illustrate where continuous quality improvement initiatives could be implemented. LHINs, hospitals and regional maternal‐child programs can examine their data in these areas and design quality improvement programs to improve these indicators where needed.

Future direction:

With the development of the new BORN Ontario database that will be implemented in the fall of 2011, it will be soon possible to examine new variables related to maternal child health, for example, maternal pre‐pregnancy body mass index, pregnancy weight gain, Bishop’s Score and pregnancy outcomes for women with a positive maternal serum screen. The database has been designed to collect data by encounter, which is a health care interaction involving a patient and the provision of services (e.g., a lab test; a delivery; an ultrasound, a newborn screening), and will collect data from multiple encounters during pregnancy, birth and early childhood. With this system architecture, it will be possible to look at individual encounters as well as to look the full perinatal care continuum. Of course, with expansion, ensuring data quality is a high priority. The new BORN database will have improved real‐time data verification processes to prevent errors and identify data discrepancies prior to saving a record. Data provided by the BORN system will help inform health system planners, funders, policy makers, care providers, and women and families about care practices in Ontario. Feedback of data is one of the first steps to enhance awareness of what is being done well and areas for improvement in care. One feedback mechanism that is under development for the new BORN Ontario database is a standardized clinical dashboard to measure performance on key maternal newborn indicators. This innovative project will help Ontario hospitals meet the requirements set out in the newly legislated Excellent Care for All Act (2010) by helping them identify areas where they are doing well and areas where there is room for improvement. BORN Ontario looks forward to being an important partner for transforming data into information and knowledge to help Ontario mothers, children and families have the best possible beginnings to lifelong health.


Introduction This report is based on data primarily from the 2009–2010 fiscal year; however, five‐year trends are presented for some variables. The data originate chiefly from the BORN Ontario–Niday Perinatal Database, but also includes other sources of data. The report is divided into six chapters: Regional Profile; Pregnancy; Maternity Health Services; Birth; Postpartum and Newborn; and Maternal and Newborn Screening. The objectives of this report are to: Highlight maternal‐newborn issues and trends arising from the analysis

Present a baseline for future examination of trends

As of November 2009, all hospitals in Ontario with maternal‐newborn services are contributing data to the Niday Perinatal Database within BORN. However, for this report of the 2009–2010 fiscal year, it is estimated that approximately 97% of the hospital births in the province were captured. As the new BORN Ontario database is developed throughout 2010–2011, all BORN founding partners will be contributing data and we expect to have a more robust system capable of longitudinal analysis of mothers, fetuses and newborns. This year, for the first time, we are able to provide reports for all areas of the province. With the exception of a few figures in Chapter 1, the unit of analysis in this report is the Local Health Integration Network1 (LHIN) region, based on the deliveries that take place in a hospital in one of the LHINs in the region (i.e., based on location of birth). For the companion series of reports on public health units, the unit of analysis is the public health region, based on maternal residence in the region, as opposed to location of birth. Both series of reports (available on the BORN website: www.bornontario.ca) differ from previous reports in several ways. Each indicator is now accompanied by its definition, including clarification of the numerator and denominator used for calculation. For graphs that provide a breakdown by individual LHIN, comparison at the regional and the provincial level is provided. Where five‐year trends are reported, we have added 95% confidence levels to the estimates. We will continue to improve reports as BORN Ontario grows and develops. Future reporting plans include adding GIS mapping for some indicators, as well as increasing the number of indicators for which we provide confidence intervals. We welcome your comments about how reports can change and improve in the future to best meet your needs. If you have specific requests for new indicators, suggestions to change existing indicators, or ideas for specialized reports, please contact a member of the BORN Ontario team (see APPENDIX A for contact information). Finally, because BORN Ontario is a web‐based system, we are able to add data variables to respond to emerging health issues. The most recent example is our collection of three variables on H1N1 and other influenza‐like illnesses in pregnancy, treatment with antiviral medication and receipt of influenza vaccine during pregnancy. This process was implemented on November 2, 2009 for a one‐year data collection period. Please visit the BORN Ontario website for more information and to view reports on the findings for this data collection initiative.


Methods Data Sources This report was prepared using data from several of the BORN Ontario databases, but the majority of data presented in this report originate from the BORN–Niday Perinatal Database. Information for all births (live births and stillbirths) at ≥20 weeks’ gestational age is collected in the Niday Perinatal Database. The database does not collect information on pregnancies that end in miscarriage before 20 weeks’ gestation or terminations of pregnancy for fetal anomalies at any gestational age. The Niday Perinatal Database is a web‐based system into which data on mothers and babies are directly entered either by care providers or data entry clerks, or extracted and uploaded by a hospital’s electronic patient record. The Niday Perinatal Database has been operating in Eastern and Southeastern Ontario since 1997 and has undergone tremendous expansion in recent years. In 2009–2010, the principal time period reflected in this report, approximately 97% of all hospital births in Ontario were entered into the database. As of November 2009, all hospitals in the province with a maternal‐newborn program are now engaged with BORN Ontario; therefore, future reports will be able to provide a complete, population‐based picture of perinatal health in the province of Ontario. BORN Ontario recently compared the number of hospital births captured in the Niday Perinatal Database with those captured in the Canadian Institute for Health Information’s Discharge Abstract Database (DAD). The table below shows the number of hospital births captured by the Niday Perinatal Database, expressed as a proportion of the total number of hospital births captured in the DAD over five fiscal years. It is important to consider this expansion of data collection activities in relation to the graphs that present 5‐year trends in this report, since a change in a rate over time may be due to an improvement in data capture rather than a true temporal trend.

Fiscal year Total number of ON hospital births

2004–2005 2005–2006 2006–2007 2007–2008 2008–2009

BORN 113,220 120,803 125,724 136,980 139,278

DAD 137,996 139,159 141,173 144,240 142,896

% captured by BORN 82.05% 86.81% 89.06% 94.97% 97.47%


Indicators The process for choosing indicators for the LHIN reports primarily consisted of looking at previous reports by the Child Health Network (CHN) in the Greater Toronto Area (GTA) and the Perinatal Partnership Program of Eastern and Southeastern Ontario (PPPESO).2,3 Both of these groups had active Niday Perinatal Database subcommittees that advised them on data needs. Consultations with these groups were held in the spring and summer of 2009 to gain further insight on types of analysis. Additionally, in response to advice provided by the Scientific Working Group of BORN, national perinatal surveillance reports4,5 were reviewed to ensure consistency between provincial and national reporting and to enhance our ability to contribute to national data initiatives. Data Analysis This report presents maternal and infant data primarily for births that occurred during the fiscal year 2009–2010 (April 1, 2009–March 31, 2010); however, selected indicators are presented for a time period of five fiscal years, from April 1, 2005–March 31, 2006 to April 1, 2009–March 31, 2010. A 5‐year dataset was extracted from the Niday Perinatal Database in September 2010. Only hospital births to residents of Ontario were included in the dataset (records in the Niday Database for home births and for births in Ontario hospitals to women from other Canadian provinces/territories or from other countries were excluded). Hospital births attended by midwives are included in these analyses. Information on home births attended by midwives was provided by the Ontario Midwifery Program and is included in this report, but presented separately (see Figure 1.7). The majority of the information in this report is analyzed by LHIN of birth. When hospitals enter maternal‐newborn data into the Niday Perinatal Database, records are automatically assigned to a LHIN based on the location of the hospital. A few figures in Chapter 1 of this report also present data based on LHIN of maternal residence. The process for assigning LHIN of maternal residence is based on the methodology developed by the Ontario Ministry of Health and Long‐Term Care, whereby residential postal code information is merged to the July 2009 Postal Code Conversion File and subsequently to the LHIN Version 11 correspondence file. A manual process of assigning records to a LHIN of maternal residence is carried out, where possible, if the postal code is invalid or unknown using other data fields. This report presents descriptive statistics, predominantly proportions. No statistical tests have been conducted on these data; therefore, differences in estimates across subgroups, or over time are not necessarily statistically significant and should be interpreted cautiously. In order to quantify the precision of the point estimates (i.e., proportions) for indicators that are presented over a five‐year period, 95% confidence intervals were calculated. The 95% confidence interval can be defined as a range that contains the true value of the point estimate 95% of the time.6 The width of the 95% confidence interval conveys important information about the variability of the point estimate –– the narrower the confidence interval, the less variability and the greater the precision of the estimate. To a certain extent, the 95% confidence interval can provide useful information for comparing two rates. A very clear description of this application in the context of perinatal data can be found in Appendix B of the Canadian Perinatal Health Report, 2008 Edition.4 Nevertheless, it is important to be mindful that the BORN–Niday Perinatal Database has been evolving rapidly in recent years, and temporal changes in some estimates over the 2005–2006 to the 2009–2010 time period may be related to changes in the


number of hospitals that contributed birth records to the database or the completeness of data collection over this five‐year period. Every effort has been made to present data with enough detail to be meaningful, while upholding BORN’s responsibility to protect the confidentiality of individual mothers, infants, care providers, and health care facilities. For this report, information is presented in aggregate form. Where aggregate information was based on five or fewer records, the information was either excluded from the report or was aggregated at a higher level. Records that were missing information for a particular indicator were excluded from analyses of that indicator. As a result, the effective denominator size used for analysis occasionally varied across graphs. Footnotes have been added to the figures to alert the reader when more than 10% but less than 30% of records for a particular estimate were missing information. Due to validity concerns, we excluded estimates for which ≥30% of records were missing information for that indicator. Footnotes have also been added where needed to clarify other aspects of data quality. Data Presentation Most of the data in this report are presented using bar graphs and line graphs. When reviewing each figure, it is important to be cognizant of the scale (i.e., the y‐axis) and the denominator, as both of these parameters will vary from graph to graph depending on the indicator being presented. At the bottom of each figure, a definition of the indicator, including information on the numerator and denominator, is provided. Additionally, data tables and data labels have been used in all graphs for clarity. Throughout the report, many of the indicators have been presented by LHIN of birth. These graphs present the estimate(s) for each LHIN, and for comparison purposes also present the LHIN region as a whole, and the overall estimate for the province of Ontario. Data Quality In 2009, a quality audit of the BORN–Niday Perinatal Database was completed. In this audit, information from the patient record was re‐abstracted in order to assess concordance (accuracy and completeness) between the data in the database and the original maternal and infant charts. An additional component of this audit was to survey database stakeholders to learn more about site‐specific data collection and entry processes, report generation capability and overall usefulness of the database. A manuscript from this project has been accepted for publication in a scientific journal.7 Results from the full report are available by contacting BORN Ontario. BORN Ontario also performs ongoing data quality checks. At quarterly and annual intervals, data are downloaded and compiled into standardized data quality reports. This process requires each hospital to verify the number of births per month, address data elements with greater than 5% missing data, and respond to individual records that appear to contain logic conflicts. These ongoing activities, as well as the results of the 2009 Niday Perinatal Database data quality audit, are used to improve the system and help sites collect and enter data more efficiently. For example, more logic and verification rules that question conflicts when data are entered have been added and the number of mandatory data fields has been increased. To further enhance data quality and consistency, a data normalization exercise has been


undertaken as part of the build of the new BORN database to reduce duplication of data collection among the partners.

References 1. Ontario’s Local Health Integration Networks. About LHINs [Internet]. Local Health Integration Network. 2010

[cited 14 Jul 2010]. Available from: http://www.lhins.on.ca/aboutlhin.aspx?ekmensel=e2f22c9a_72_184_btnlink.

2. Child Health Network (CHN). Niday Perinatal Database for the GTA: Fifth Annual Statistical Report 2007/2008 [Internet]. Toronto, Ontario: CHN; 2008 [cited 26 Nov 2009]. Available from: https://www.nidaydatabase.com/info/pdf/Niday_07‐08_Final‐updated.pdf.

3. Perinatal Partnership Program of Eastern and Southeastern Ontario (PPPESO). Annual Perinatal Statistical Report 2007/2008 [Internet]. Ottawa, Ontario: PPPESO; 2008 [cited 26 Nov 2009]. Available from: http://www.pppeso.on.ca/site/pppeso/NIDAY_Perinatal_Database_p484.html.

4. Public Health Agency of Canada. Canadian Perinatal Health Report, 2008 Edition. Ottawa, 2008.

5. Public Health Agency of Canada. What Mothers Say: The Canadian Maternity Experiences Survey. Ottawa, 2009.

6. Rothman KJ, Greenland S, Lash TL editors. Modern Epidemiology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008.

7. Dunn S, Bottomley J, Ali A, Walker M. 2008 Niday Perinatal Database quality audit: report of a quality assurance project. Chronic Diseases in Canada [In press].


Introduction The Greater Toronto Area (GTA) is comprised of the City of Toronto and surrounding regional municipalities of Durham, York, Peel and Halton. With over 5 million people and more than 140 languages and dialects spoken, the GTA is the largest and most diverse metropolitan area in Canada.1 More than half of the province’s births take place at a hospital in the GTA. The GTA Local Health Integration Network (LHIN) Region includes LHINs 5 to 9. Together, these five LHINs include an estimated population of 5,803,606.

LHIN Number LHIN Name Population

5 Central West 739,957 6 Mississauga Halton 1,008,004 7 Toronto Central 1,090,301 8 Central 1,532,649 9 Central East 1,432,695

5–9 GTA REGION 5,803,606

Source: Statistics Canada. 2006 Community Profiles [cited 20 Apr 2010]. Available from: http://www12.statcan.gc.ca/census‐recensement/2006/dp‐pd/prof/92‐591/index.cfm?Lang=E.

Source: Cancer Care Ontario: Insight on Cancer. News and Information on Breast Cancer and Screening in Ontario. Toronto: Canadian Cancer Society (Ontario Division), October, 2007 [cited 28 Mar 2011]. Available from: http://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=13832.

CHAPTER 1 PROFILE OF GREATER TORONTO AREA LHIN REGION AND OBSTETRICAL POPULATION


During this reporting period, the Child Health Network (CHN) was an active partner in the delivery of maternal‐newborn services in the GTA. The CHN worked with hospital and community providers in the GTA and developed a shared vision to promote a sustainable and responsive maternal, newborn, and child health care system.2 The CHN closed in September 2010. BORN Ontario, in partnership with the Provincial Council for Maternal Child Health (PCMCH), is committed to continuing the important work initiated by the CHN with respect to facilitating partnerships, sharing data and supporting quality improvement strategies within the GTA. This report presents data for Ontario women who gave birth in a hospital in one of the five LHINs of the GTA region. Readers of previous GTA reports produced by the CHN should note that this report expands the boundaries of the CHN, and therefore will differ slightly from previous GTA reports. The total number of GTA hospital sites whose data are included in this report can be found in APPENDIX C. Women who resided in the GTA and gave birth at home under the care of a midwife are presented separately within this report (see Figure 1.7). The first set of figures in this chapter portrays the distribution of births across the region. Although the majority of women in the GTA give birth in the LHIN in which they reside, there is considerable mobility across LHIN boundaries. Clinical reasons prompt some of this movement, as some women will need to travel in order to access specialized care, but the reasons why women travel to give birth cannot always be determined from the data available within the BORN–Niday Perinatal Database. Geographical proximity to a hospital in a neighbouring LHIN, access to care providers, capacity issues,3 change of residence during pregnancy and seeking care near to one’s workplace rather than one’s residence may all contribute to these patterns. Awareness of these patterns is essential for health services planning to ensure that the health care system supports appropriate continuity of care for mothers and babies when they return to their home communities, and to ensure that adequate levels of service are available as close to home as possible.


Figure 1.1 Number of women who gave birth, by LHIN of birth and fiscal year

Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010

Data source BORN Ontario (Niday Perinatal Database), 2005–2006 to 2009–2010

Local Health Integration Network (LHIN) based on hospital of birth

Definition of indicator The number of women who gave birth in a hospital in one of the five LHINs in the Greater Toronto Area (GTA) in 2005–2006 to 2009–2010.

Notes: 1. The total number of women who gave birth in a GTA hospital by fiscal year was: 2005–2006: 68,688; 2006–2007: 70,388; 2007–2008: 71,936; 2008–2009: 71,887; 2009–2010: 71,780.

The number of women who gave birth in a hospital in one of the five LHINs in the GTA in 2009–2010 was 71,780. This represents 52.7% of the total number of Ontario women who gave birth in an Ontario hospital in 2009–2010 (136,223). The GTA LHIN with the largest number of women who had a hospital birth in 2009–2010 was Toronto Central LHIN (19,291).

Between 2005–2006 and 2009–2010, the total number of women who gave birth in a hospital in the GTA LHIN Region increased by 4.5% from 68,688 to 71,780.

Although Central LHIN is a region of growth, some of the increase in the number of women who gave birth in a Central LHIN hospital from 2006–2007 to 2007–2008 can be attributed to the adoption of the Niday Perinatal Database by Headwater Healthcare Centre in Orangeville in 2006–2007 and by Stevenson Memorial Hospital in Alliston commencing in the spring of 2008.


Figure 1.2 Number of women who gave birth, by LHIN of maternal residence and fiscal year



Local Health Integration Network (LHIN) based on maternal residence

Definition of indicator The number of women residing in each LHIN in the Greater Toronto Area (GTA) who gave birth in hospital in 2005–2006 to 2009–2010.

Notes: 1. The total number of women who resided in a GTA LHIN and gave birth in hospital by fiscal year was: 2005–2006: 67,432; 2006–2007: 69,299; 2007–2008: 71,004; 2008–2009: 70,882; 2009–2010: 70,734.

2. A small number of women in each fiscal year who gave birth in a GTA hospital, but could not be mapped to a LHIN of maternal residence were excluded. It is possible that some of these women were GTA residents.

3. The numbers presented in this graph may differ from previous GTA reports using the Niday Perinatal Database as a result of updates and modifications to the database or the methodology of assigning postal codes to LHIN of maternal residence.

The number of women who resided in one of the five LHINs in the GTA and gave birth in 2009–2010 was 70,734. This represents 51.9% of the total number of Ontario women who gave birth in an Ontario hospital in 2009–2010 (136,223). The GTA LHIN with the largest number of residents who had a hospital birth in 2009–2010 was Central LHIN (18,570).

The total number of GTA residents with a hospital birth recorded in the database increased by 4.9% from 67,432 in 2005–2006 to 70,734 in 2009–2010.


Figure 1.3 Number of total births, by LHIN of birth and fiscal year




Definition of indicator The number of total births (live births and stillbirths) to Ontario women in a hospital in one of the five LHINs in the Greater Toronto Area (GTA) in 2005–2006 to 2009–2010.

Notes: 1. The number of total births in a GTA hospital by fiscal year was: 2005–2006: 69,888; 2006–2007: 71,616; 2007–2008: 73,241; 2008–2009: 73,255; 2009–2010: 73,169.

The number of total births (live births and stillbirths) in a hospital in one of the five LHINs in the GTA in 2009–2010 was 73,169. This represents 52.7% of the total number of hospital births in Ontario in 2009–2010 (138,775). The GTA LHIN with the largest number of hospital births in 2009–2010 was Toronto Central LHIN (19,871).

Between 2005–2006 and 2009–2010, the number of total births in a hospital in the GTA LHIN Region increased by 4.6% from 69,888 to 73,169.

The number of total births at each hospital site in the GTA region can be found in APPENDIX C.


Figure 1.4 Number of total births, by LHIN of maternal residence and fiscal year



Local Health Integration Network (LHIN) based on maternal residence

Definition of indicator The number of total hospital births (live births and stillbirths) to residents of each LHIN in the Greater Toronto Area (GTA) in 2005–2006 to 2009–2010.

Notes: 1. The number of total hospital births to women who resided in a GTA LHIN by fiscal year was: 2005–2006: 68,599; 2006–2007: 70,494; 2007–2008: 72,285; 2008–2009: 72,211; 2009–2010: 72,102.

2. A small number of births in each fiscal year were excluded because they occurred in a GTA hospital, but could not be mapped to a LHIN of maternal residence. It is possible that some of these births were to GTA residents.

3. The numbers presented in this graph may differ from previous GTA reports using the Niday Perinatal Database as a result of updates and modifications to the database or the methodology of assigning postal codes to LHIN of maternal residence.

The number of total births to women who resided in one of the five LHINs in the GTA in 2009–2010 and gave birth in hospital was 72,102. This represents 52.0% of the number of total hospital births in Ontario in 2009–2010 (138,775). Central LHIN residents had the largest number of total hospital births (18,919) in 2009–2010 in the GTA.

The number of total hospital births to GTA residents recorded in the database increased by 5.1% from 68,599 in 2005–2006 to 72,102 in 2009–2010.


Figure 1.5a Distribution of LHIN of maternal residence among women who had a hospital birth in

the GTA, by LHIN of birth Greater Toronto Area (GTA) LHIN Region, 2009–2010

LHIN of birth

Central West Mississauga

Halton Toronto Central

Central Central East

GTA

n % n % n % n % n % n %

Central West

6,987 88.4 1,759 13.9 935 4.9 1,238 6.8 51 0.4 10,970 15.3

Mississauga Halton

281 3.5 9,962 78.8 1,506 7.8 212 1.2 45 0.3 12,005 16.7

Toronto Central

52 0.7 166 1.3 11,322 58.8 1,146 6.3 400 2.9 13,086 18.2

Central 477 6.0 111 0.9 3,482 18.1 13,010 71.7 1,415 10.3 18,495 25.8

Central East

11 0.1 13 0.1 1,713 8.9 2,224 12.2 11,711 85.1 15,672 21.8

LHIN of maternal residence

Non‐GTA LHIN

100 1.3 638 5.0 304 1.6 326 1.8 145 1.1 1,513 2.1

Total number of women 7,907 100.0 12,649 100.0 19,263 100.0 18,155 100.0 13,768 100.0 71,742 100.0

Data source BORN Ontario (Niday Perinatal Database), 2009–2010

Definition of indicator The distribution of LHIN of maternal residence, expressed as a percentage of the total number of women

who gave birth in a hospital in one of the five LHINs in the Greater Toronto Area (GTA) in 2009–2010.

Notes: 1. 38 women who gave birth in a hospital in one of the five LHINs of the GTA were excluded from the figure due to incomplete address information or no fixed residential address resulting in unknown LHIN of maternal residence.

In 2009–2010, of the women who gave birth in a hospital in the Central West LHIN, the majority (88.4%) were residents of Central West LHIN. Similarly, in Central East LHIN, 85.1% of the women who gave birth in a Central East hospital were residents of that LHIN.

In contrast, less than two‐thirds (58.8%) of the women who gave birth in a hospital in Toronto Central LHIN were residents of the LHIN.

Mississauga Halton had the highest proportion of births to women who were residents of a LHIN outside the GTA (5.0%), the majority of whom were residents of the Hamilton Niagara Haldimand Brant LHIN (LHIN 4).


Figure 1.5b Proportion of women who had a hospital birth in their LHIN of residence, by LHIN of

birth Greater Toronto Area (GTA) LHIN Region, 2009–2010


Definition of indicator The number of women who resided in the LHIN in which they gave birth, expressed as a percentage of

the total number of women who gave birth in a hospital in one of the five LHINs in the Greater Toronto Area (GTA) in 2009–2010.


Among the women who gave birth in a hospital in the GTA LHIN Region in 2009–2010, almost three‐quarters (73.9%) were residents of the LHIN in which they gave birth. Considerable variation was evident across the five LHINs of the GTA, from a low of 58.8% of women who gave birth in Toronto Central to a high of 88.4% of women who gave birth in Central West.


Figure 1.6a Distribution of LHIN of hospitals among GTA residents who had a hospital birth, by

LHIN of maternal residence Greater Toronto Area (GTA) LHIN Region, 2009–2010

LHIN of maternal residence

Central West Mississauga

Halton Toronto Central

Central Central East

GTA

n % n % n % n % n % n %

Central West

6,987 63.2 281 2.3 52 0.4 477 2.6 11 0.1 7,807 11.0

Mississauga Halton

1,759 15.9 9,962 81.6 166 1.3 111 0.6 13 0.1 12,011 17.0

Toronto Central

935 8.5 1,506 12.3 11,322 86.4 3,482 18.8 1,713 10.8 18,959 26.8

Central 1,238 11.2 212 1.7 1,146 8.7 13,010 70.1 2,224 14.1 17,829 25.2

Central East

51 0.5 45 0.4 400 3.1 1,415 7.6 11,711 74.2 13,623 19.3

LHIN of

birth

Non‐GTA LHIN

79 0.7 210 1.7 21 0.2 75 0.4 120 0.8 504 0.7

Total number of women

11,049 100.0 12,215 100.0 13,107 100.0 18,570 100.0 15,792 100.0 70,734 100.0


Definition of indicator The distribution of LHIN of maternal residence, expressed as a percentage of the total number of women

who gave birth in a hospital in one of the five LHINs in the Greater Toronto Area (GTA) in 2009–2010.


Among the 70,734 women who resided in one of the five LHINs in the GTA and gave birth in 2009–2010, the proportion who delivered in a hospital in the same LHIN as they resided was highest among residents of Toronto Central (86.4%) and Mississauga Halton (81.6%) and lowest among residents of Central West (63.2%).

Among residents of the GTA LHIN Region who gave birth in 2009–2010, Mississauga Halton had the highest proportion of residents who delivered in an Ontario hospital outside the GTA LHIN Region (1.7%). The majority of these births occurred in the Hamilton Niagara Haldimand Brant LHIN.


Figure 1.6b Proportion of women who had a hospital birth in their LHIN of residence, by LHIN of

maternal residence Greater Toronto Area (GTA) LHIN Region, 2009–2010


Definition of indicator The distribution of LHIN of birth (birth occurs in the LHIN in which they reside, in another LHIN in the

GTA, or in another Ontario LHIN outside the GTA), expressed as a percentage of the total number of residents in one of the five LHINs in the Greater Toronto Area (GTA) who had a hospital birth in 2009–2010.


Among the 70,734 women who resided in the GTA LHIN Region and gave birth in 2009–2010, about three‐quarters (74.9%) delivered in a hospital in the LHIN where they resided. Variability across the five LHINs of the GTA region was evident, however, from a low of 63.2% of women who resided in Central West to a high of 86.4% of women who resided in Toronto Central.


Choice of birthplace Choice of birthplace is a key component of the model of midwifery care in Ontario – midwives are expected to provide intrapartum care in both the home and the hospital setting, and to support women’s choices. Prenatally, midwives provide each woman with sufficient information in order for her to make an informed decision about where she will plan to give birth. This decision typically involves consideration of any risk factors present in the pregnancy; the distance between the woman’s home and the nearest hospital(s), and the level of obstetrical services available; research evidence regarding the benefits and risks of home and hospital birth; and the woman’s own preferences. The College of Midwives of Ontario has established standards which indicate specific circumstances in which a hospital birth should be planned (e.g., multiple birth, breech, preterm labour, and gestational age of more than 43 completed weeks).4 The College’s standards also identify situations in which consultation with or transfer of care to a physician is necessary, which frequently leads to a plan for a hospital birth.5

Two Canadian studies have demonstrated that planned home birth is associated with good maternal and neonatal outcomes when midwives are integrated into the health system with good access to emergency services.6,7 The integration of midwives within the health care system, good communication between all maternity care providers, and supportive relationships with the hospital teams that provide essential care when serious complications arise, all help to ensure that mothers and babies receive the best possible care.


Figure 1.7 Number of women in midwifery care that gave birth at home, by LHIN of maternal

residence Greater Toronto Area (GTA) LHIN Region, 2009–2010

Data source Ontario Midwifery Program Maternal‐Newborn Health Reporting System (Ontario Ministry of Health

and Long‐Term Care), 2009–2010 Local Health Integration Network (LHIN) based on maternal residence

Definition of indicator The number of women residing in the Greater Toronto Area (GTA) who gave birth at home in 2009–2010 under the care of a midwife.

Notes: 1. The numbers presented are reflective of the number of babies born between April 1, 2009 and March 31, 2010.

The number of women who gave birth at home under the care of a midwife in the GTA in 2009–2010

was 967. This represents 1.3% of the total births to residents of the region (967 out of 72,102 hospital births + 967 home births) and 35.7% of the total number of home births under the care of a midwife in Ontario in 2009–2010 (967 out of 2,711). Note that the Ontario total includes 34 records that could not be mapped to a LHIN of residence (either due to missing or invalid postal code information). It is possible that some of these records were for GTA residents.

Across the five GTA LHINs, the median maternal age of women who gave birth at home under midwifery care in 2009–2010 was 32 years, 22.6% of women were pregnant for the first time (i.e., gravida=1) and 1.8% of women smoked during their pregnancy.

The median gestational age at birth of babies born at home under midwifery care in 2009–2010 was 39 weeks across the five GTA LHINs. Median birth weight was 3,540 grams. A high proportion of babies were being exclusively breastfed at three days following birth (92.8%).


Maternal Age

Teen Pregnancy and Birth

Although the proportion of live births to teenage mothers decreased in Canada between 1995 and 2004,8 Canada’s teenage birth rate is six times higher than that of Japan and Switzerland and more than twice that of Sweden and Finland.9 According to Statistics Canada, in 2007, the proportion of live births to mothers 10‐19 years of age was 4.2% in Canada and 3.4% in Ontario.10 Inadequate prenatal care, physical and sexual abuse, increased likelihood of social deprivation, drug use and smoking,11 poor nutrition resulting in poor maternal weight gain and anemia11,12 and premature termination of education12,13 are all factors that place teen mothers and their infants at greater risk for preterm and/or low birth weight,11,12 and increased perinatal mortality.12,14–16 Teen mothers, particularly those with limited social support, are more likely to experience postpartum depression,17 and they are less likely to breastfeed.16 Advanced Maternal Age Increasingly, women are delaying childbearing – in Canada, the proportion of live births to older mothers (>35 years of age) steadily increased between 1995 and 2004.18 In 2007, the proportion of live births to mothers 35‐49 years of age was 18.0% in Canada and 21.2% in Ontario.10 This trend is important because of the association between higher maternal age and increased maternal morbidity (including gestational hypertension and diabetes), cesarean delivery, multiple gestation pregnancy and adverse pregnancy outcomes (including chromosomal abnormalities, miscarriage, low birth weight, small for gestational age, preterm birth, perinatal mortality and serious neonatal morbidity).19–22 Health care providers and public education campaigns should inform all women of child‐bearing age of the potential risks of advanced maternal age as a means to support informed decisions about the timing of child bearing.23 Despite the higher risk of perinatal morbidity and mortality with increased maternal age, older first‐time mothers often have a higher level of education and socioeconomic status, seek prenatal care earlier and receive good quality maternity care.24 Since higher socioeconomic status is associated with a lower prevalence of risk factors such as pre‐pregnancy obesity and smoking during pregnancy,25 older women, especially those who have no chronic conditions, generally have healthy pregnancies and healthy babies.26


Figure 1.8 Distribution of maternal age, by LHIN of birth

Greater Toronto Area (GTA) LHIN Region, 2009–2010



Definition of indicator The distribution of categories of maternal age in years at the time of birth, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time).

62.2% of women who gave birth in the GTA LHIN Region in 2009–2010 were between the ages of 25 and 34 years.

The proportion of births to teenage women (less than 20 years of age) in 2009–2010 was 2.2%. The LHIN with the highest proportion of births to teenage women in 2009–2010 was Central East (3.9%).

The proportion of births to women 35 years of age and over in 2009–2010 in the GTA LHIN Region was 25.4%, higher than the overall background proportion of 21.4% in Ontario. The LHIN with the highest proportion of births to women 35 years of age and over in 2009–2010 was Toronto Central (32.9%). Approximately 18% of women who gave birth in Central West and Central East LHINs were ≥35 years of age.


Figure 1.9 Proportion of women who were <20 years at delivery, by fiscal year




Definition of indicator The number of women <20 years of age who gave birth, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time).

The proportion of women who gave birth in the GTA LHIN Region who were <20 years of age remained fairly constant between 2005–2006 and 2009–2010. In 2009–2010, 2.2% (95% CI: 2.1–2.3) of women who gave birth in the region were under the age of 20 years.


Figure 1.10 Proportion of women who were >35 years at delivery, by fiscal year




Definition of indicator The number of women >35 years of age who gave birth, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time).

Between 2005–2006 and 2009–2010, the proportion of women giving birth in the GTA who were >35 years of age increased slightly, from 23.6% (95% CI: 23.3–23.9) in 2005–2006 to 25.4% (95% CI: 25.1–25.7) in 2009–2010.


Figure 1.11 Distribution of parity, by LHIN of birth




Definition of indicator The distribution of parity, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time). For this report, parity is defined as the number of previous live births or stillbirths (0, 1, >2), not including the current pregnancy.

44.8% of the women who gave birth in the GTA LHIN Region in 2009–2010 were first‐time mothers (i.e., parity = 0), very similar to the background rate for the province (44.1%). The LHIN with the highest proportion of first‐time mothers was Toronto Central (49.7%) and the lowest proportion of first‐time mothers was in Central West LHIN (41.1%).


Figure 1.12 Proportion of women who were ≥35 years and nulliparous at delivery, by LHIN of birth




Definition of indicator The number of deliveries to women who were nulliparous (parity=0), expressed as a percentage of the total number of women who were ≥35 years of age at delivery and who had a live birth or stillbirth (in a given place and time).

The proportion of women 35 years of age or older who were nulliparous (i.e., parity = 0) at the time of delivery was 28.9% across the GTA LHIN Region. This ranged from a high of 37.3% in Toronto Central to a low of 19.6% in Central West. Across Ontario, 27.7% of women 35 years of age or older who gave birth in 2009–2010 were nulliparous.


Figure 1.13 Proportion of women who were ≥35 years and nulliparous at delivery, by fiscal year




Definition of indicator The number of deliveries to women who were nulliparous (parity=0), expressed as a percentage of the total number of women who were ≥35 years of age at delivery and who had a live birth or stillbirth (in a given place and time).

Between 2005–2006 and 2009–2010, the proportion of women 35 years of age or older who were

nulliparous (i.e., parity = 0) at the time they gave birth in a GTA hospital remained fairly constant. In 2009–2010, 28.9% (95% CI: 28.2–29.6) of women 35 years of age or older at delivery were nulliparous.


References

1. City of Toronto. Toronto facts [cited 20 Apr 2010]. Available from: http://www.toronto.ca/toronto_facts/diversity.htm.

2. Child Health Network (CHN) for the Greater Toronto Area. What is the CHN [Internet]? [cited 20 Apr 2010]. Available from: http://www.childhealthnetwork.com/chn/what.php.

3. Child Health Network (CHN). Niday Perinatal Database for the GTA: Fifth Annual Statistical Report 2007/2008 [Internet]. Toronto, Ontario: CHN;2008 [cited 10 May 2010]. Available from: http://childhealthnetwork.com/chn/pdfs/NidayPerinatal‐FifthAnnualReport‐2008.pdf.

4. College of Midwives of Ontario. Indications for Planned Place of Birth. Toronto: CMO, 1994.

5. College of Midwives of Ontario. Indications for Mandatory Discussion, Consultation, and Transfer of Care. Toronto: CMO, 2000.

6. Hutton EK, Reitsma AH, Kaufman K. 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 2009;36:180–9.

7. Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ 2009;181(6–7):377–83.

8. Huang L, Kimak C. Rate of live births to teenage mothers. In: Canadian Perinatal Health Report, 2008 Edition. Public Health Agency of Canada. Ottawa, 2008. p. 62–6.

9. Public Health Agency of Canada. A framework for action to reduce the rate of teen pregnancy in Canada. Ottawa, ON: Public Health Agency of Canada; 2000.

10. Statistics Canada. Births 2007. Ottawa: Ministry of Industry; 2009. Catalogue no. 84F0210X.

11. World Health Organization. Adolescent pregnancy: Issues in adolescent health and development. Geneva, Switzerland: World Health Organization; 2004.

12. Klein JD. Adolescent pregnancy: current trends and issues. Pediatrics 2005;116(1):281–6.

13. Rotermann M. Second or subsequent births to teenagers. Health Rep 2007;18(1):39–42.

14. Chen XK, Wen SW, Fleming G, Demisse K, Rhoads GG, Walker M. Teenage pregnancy and adverse birth outcomes: A large population based retrospective cohort study. Int J Epidemiol 2007;36(2):368–73.

15. Gortzak‐Uzan L, Hallak M, Press F, Katz M, Shoham‐Vardi I. Teenage pregnancy: Risk factors for adverse perinatal outcomes. J Matern Fetal Med 2001;10(6):393–7.

16. Stewart A, Walsh J, Van Eyk N. Adverse outcomes associated with adolescent pregnancy. J Pediatr Adolesc Gynecol 2008;21(2):59–60.

17. Reid V, Meadows‐Oliver M. Postpartum depression in adolescent mothers: An integrative review of the literature. J Pediatr Health Care 2007;21:289–98.

18. Huang L, Royle C, Boscoe M. Rate of live births to older mothers. In: Canadian Perinatal Health Report, 2008 Edition. Public Health Agency of Canada. Ottawa, 2008. p. 67–71.

19. Heffner LJ. Advanced maternal age ‐ how old is too old? NEJM 2004;351(19):1927–9.

20. Joseph KS, Allen AC, Dodds L, Turner LA, Scott H, Liston R. The perinatal effects of delayed childbearing. Obstet Gynecol 2005;105(6):1410–8.

21. Lynch A, McDuffie R, Murphy J, Faber K, Leff M, Orleans M. Assisted reproductive interventions and multiple birth. Obstet Gynecol 2001;97(2):195–200.

22. Jolly M, Sebire N, Harris J, Robinson S, Reagan L. The risks associated with pregnancy in women aged 35 years or older. Hum Reprod 2000;15(11):2433–7.

23. Benzies KM. Advanced maternal age: Are decisions about the timing of child‐bearing a failure to understand the risks? CMAJ 2008;178(2):183–4.

24. Neumann M, Graf C. Pregnancy after age 35. AWHONN Lifelines 2003;7(5):422–30.

25. Olsen J, Frische G. Social differences in reproductive health. A study on birth weight, stillbirths and congenital malformations in Denmark. Scand J Soc Med 1993;21(2):90–7.

26. Dildy GA, Jackson GM, Fowers GK, Oshiro BT, Varner MW, Clark SL. Very advanced maternal age: Pregnancy after age 45. Am J Obstet Gynecol 2009;75(3 Pt 1):668–74.


Maternal and fetal health during pregnancy are influenced by many factors that include maternal health status prior to pregnancy, health care received during pregnancy, maternal behaviours during pregnancy (such as diet, exercise and substance use), and medical conditions that arise during pregnancy. Prenatal care aims to optimize perinatal outcomes by identifying potential risks and mitigating them through the appropriate treatment of medical conditions and through the provision of education and support to encourage risk reduction.1 Despite debate about the ideal frequency and timing of prenatal visits,2 there is general agreement that it is optimal for women to begin prenatal care early in pregnancy.1 While the vast majority of women across Canada initiate prenatal care during the first trimester, younger women (15–19 years), women with less than a high school education, and women living in a household at or below the low income cut‐off are less likely to do so.3 Pre‐pregnancy (i.e., non‐gestational) diabetes and chronic hypertension are two pre‐existing maternal medical conditions that are particularly relevant, due to their association with adverse perinatal outcomes. Diabetes prior to pregnancy is associated with a higher risk of birth defects,4,5 perinatal and infant mortality,5 as well as fetal macrosomia.5 Chronic hypertension is associated with both increased maternal morbidity (such as preeclampsia, gestational diabetes and placental abruption)6 as well as increased risk of small for gestational age at birth7 and perinatal mortality.8 Many women who have medical conditions such as these require additional evaluation and treatment during pregnancy. Information on pre‐existing maternal medical conditions has been collected by the BORN–Niday Perinatal Database since 2005 and is reported in this chapter. A complete list of conditions captured in the database can be found in APPENDIX D. Similarly, women who develop obstetrical complications during the course of their pregnancy also require enhanced assessment and treatment to manage the complications. Obstetrical complications during pregnancy have been captured by the database since 2005 (see APPENDIX E for a complete list). This consists of several of the most common obstetrical complications associated with adverse outcomes including gestational diabetes, gestational hypertensive disorders, placental conditions (placenta previa and placental abruption), preterm rupture of membranes, as well as fetal growth concerns. In the last few years, outcomes associated with assisted human reproduction (AHR) have received considerable attention in both mainstream and obstetric literature. Ovulation induction, in vitro fertilization, intracytoplasmic sperm injection and frozen embryo transfer are increasingly used in Canada to achieve pregnancy. In 2007, the number of births (live births and stillbirths) following a pregnancy achieved by AHR was at least 4,499,9 which represents approximately 1.2% of the total births in Canada for that year.10 Pregnancies conceived by AHR have been shown to be more likely to be associated with numerous adverse perinatal outcomes;11–15 however, there remain unanswered questions with respect to distinguishing the effect of AHR from the underlying infertility itself.14,15 One of the most important consequences of AHR is multifetal pregnancy – in 2006, 43.1% of live births and stillbirths following AHR in Canada were twins and 2.9% were triplets or higher order.16

CHAPTER 2 PREGNANCY


Figure 2.1 Proportion of women who did not attend an antenatal visit with a health care provider

during the first trimester, by LHIN of birth Greater Toronto Area (GTA) LHIN Region, 2009–2010



Definition of indicator

The number of women who did not attend an antenatal visit with a health care provider during the first trimester, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time).

* Between 10% and 30% of records had missing information and were excluded from the calculation of these estimates. ** Estimate not shown because more than 30% of records had missing information.

Data for Toronto Central and Central East are not presented because more than 30% of records had missing information.

In 2009–2010, the proportion of women who did not attend a first trimester prenatal care visit was 30.1% in Central West, 14.4% in Central LHIN and 7.9% in Mississauga Halton. In these LHINs, the proportion of records missing this information was 18.7%, 23.6% and 3.4%, respectively. For the province of Ontario overall, 14.1% of women did not attend a first trimester prenatal care visit (21.3% missing).

These results should be interpreted with caution because of the high proportion of records with missing data. It is unclear whether the actual proportions of women who did not receive first trimester prenatal care are higher or lower than indicated here.

** **

*

**

*


Figure 2.2 Proportion of women with pre‐existing health conditions, by fiscal year





The number of women with one or more pre‐existing health conditions, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time).

* Between 10% and 30% of records had missing information and were excluded from the calculation of these estimates. Notes: 1. A complete list of the pre‐existing maternal health condition categories collected by the database

can be found in APPENDIX D.

In 2009–2010, the most common pre‐existing conditions were other (14.4%), chronic disease (e.g., asthma, hypertension, diabetes and heart disease – 8.7%) and psychiatric disorders/mental illness (3.2%).

The proportion of women with one or more pre‐existing health conditions increased from 11.5% (95% CI: 11.3–11.8) in 2005–2006 to 24.8% (95% CI: 24.5–25.2) in 2009–2010.

In 2005–2006 and 2006–2007, the proportion of records missing this information was 19.6% and 12.7%, respectively. Comparisons across years should be interpreted with caution due to expansion of data collection activities for this variable over this five‐year period. The rate for 2009–2010 is likely to reflect the most accurate estimate of the proportion of women with one or more pre‐existing medical conditions since the data capture was more complete than in the earlier years.

*

*


Figure 2.3 Proportion of women with obstetrical complications during pregnancy, by fiscal year Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010




The number of women with one or more obstetrical complications during pregnancy, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time).

* Between 10% and 30% of records had missing information and were excluded from the calculation of these estimates. Notes: 1. A complete list of the obstetrical complication categories collected by the database can be found in

APPENDIX E.

In 2009–2010, the most common obstetrical complications were other (6.8%), gestational diabetes (6.2%) and preterm labour (2.8%), followed by premature rupture of membranes (PROM – 2.2%) and intrauterine growth restriction (2.2%).

The proportion of women with one or more obstetrical complications during pregnancy increased from 16.9% (95% CI: 16.6–17.2) in 2005–2006 to 24.3% (95% CI: 24.0–24.6) in 2009–2010.

In 2005–2006 and 2006–2007, the proportion of records missing this information was 20.0% and 12.6%, respectively. Comparisons across years should be interpreted with caution due to expansion of data collection activities for this variable over this five‐year period. The rate for 2009–2010 is likely to reflect the most accurate estimate of the proportion of women with one or more obstetrical complications during pregnancy since the data capture was more complete than in the earlier years.

**


Figure 2.4 Rate of assisted conception, by LHIN of birth





The number of women who used reproductive assistance for the current pregnancy, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time).

* Between 10% and 30% of records had missing information and were excluded from the calculation of these estimates. ** Estimate not shown because more than 30% of records had missing information. Notes: 1. At the time of data entry, only one category for this variable can be selected from the following

options: intrauterine insemination, in‐vitro fertilization, intracytoplasmic sperm injection, and ovulation induction (for example, clomiphine citrate, injectable gonadotropins, GnRH pump and bromociptine). Because there are no specific instructions currently in place with respect to which code should take priority in the event that more than one type of reproductive assistance is used to achieve the pregnancy, individual categories are not reported.

Overall, 2.6% of women who gave birth in the GTA LHIN region in 2009–2010 had used some form of reproductive assistance to achieve the current pregnancy.

These results should be interpreted with caution because of the high proportion of records with missing data. It is unclear whether the actual proportions of women who used reproductive assistance are higher or lower than indicated here.

**

*

**

*


References

1. US Department of Health and Human Services. Maternal, infant, and child health. In: Healthy people 2010. 2nd ed. [Internet]. Washington (DC): US Government Printing Office; 2000 [cited 17 Nov 2009]. Available from: http://www.healthypeople.gov/Document/HTML/Volume2/16MICH.htm#_Toc494699663.

2. Chalmers B, Mangiaterra V, Porter R. WHO principles of perinatal care: the essential antenatal, perinatal and postpartum care course. Birth 2001;28(3):202–7.

3. Heaman M. Prenatal care. In: What Mothers Say: The Canadian Maternity Experiences Survey. Public Health Agency of Canada. Ottawa, 2009.

4. Correa A, Gilboa SM, Beser LM, et al. Diabetes mellitus and birth defects. Am J Obstet Gynecol 2008;199:237.e1–9.

5. Yang J, Cummings EA, O’Connell C, Jangaard K. Fetal and neonatal outcomes of diabetic pregnancies. Obstet Gynecol 2006;108:644–50.

6. Zetterstrom K, Lindberg NS, Haglund B, Hanson U. Maternal complications in women with chronic hypertension: a population‐based cohort study. Obstet Gynecol Scand 2005;84:419–24.

7. Zetterstrom K, Lindberg NS, Haglund B, Hanson U. Chronic hypertension as a risk factor for offspring to be born small for gestational age. Acta Obstet Gynecol 2006;85:1046–50.

8. Zetterstrom K, Lindberg NS, Haglund B, Hanson U. The association of maternal chronic hypertension with perinatal death in male and female offspring: a record linkage study of 866188 women. BJOG 2008;115(11):1436–42.

9. Gunby J, Bissonnette F, Librach C, et al.; on behalf of the IVF Directors Group of the Canadian Fertility and Andrology Society. Assisted reproductive technologies (ART) in Canada: 2007 results from the Canadian ART Register. Fertil Steril 2011;95(2):542–7.e1–10. Epub 2010 Jul 24.

10. Statistics Canada. Births 2007. Ottawa: Ministry of Industry; 2009. Catalogue no. 84F0210X.

11. Hansen M, Bower C, Milne E, de Klerk N, Kurinczuk JJ. Assisted reproductive technologies and the risk of birth defects—a systematic review. Hum Reprod 2005;20(2):328–38.

12. Jackson RA, Gibson KA, Wu YW, Croughan MS. Perinatal outcomes in singletons following in vitro fertilization: a meta‐analysis. Obstet Gynecol 2004;103:551–63.

13. Schieve LA, Cohen B, Nannini A, et al., for the Massachusetts Consortium for Assisted Reproductive Technology Epidemiologic Research (MCARTER). A population‐based study of maternal and perinatal outcomes associated with assisted reproductive technology in Massachusetts. Matern Child Health J 2007;11:517–25 DOI 10.1007/s10995‐007‐0202‐7.

14. Zhu JL, Basso O, Obel C, Bille C, Olsen J. Infertility, infertility treatment, and congenital malformations: Danish national birth cohort. BMJ 2006; 333(7570):679. Epub 2006 Aug 7.

15. Zhu JL, Obel C, Bech BH, Olsen J, Basso O. Infertility, infertility treatment and fetal growth restriction. Obstet Gynecol 2007;110(6):1326–34.

16. Gunby J, Bissonnette F, Librach C, Cowan L. Assisted reproductive technologies (ART) in Canada: 2006 results from the Canadian ART Register. Fertil Steril 2009;doi:10.1016/j.fertnstert.2009.03.102.


Level of Care Levels of care in Ontario hospitals are designated by the Ontario Ministry of Health and Long‐Term Care. These designations reflect the scope of medical services available at a particular hospital and the acuity and complexity of patients cared for at that hospital. At the time this report was prepared, four levels of care designation for maternal‐newborn services existed within the GTA (see summary below).1 A list of all GTA hospitals and their corresponding level of care can be found in APPENDIX F. In May 2011, recommendations regarding new maternal and newborn levels of care designation were announced by the Provincial Council for Maternal Child Health (PCMCH). These will likely phase in over the next several years and future reports will reflect these new designations.

Level of care Description

I Provide care for healthy mothers and infants >36 weeks’ gestation

II/II+ Provide care for mothers and infants ≥32 weeks’ gestation

III Provide care for all high‐risk pregnancies, including prematurity <32 weeks

The effective operation of distinct level of care designations (supported by a defined scope of services) is a fundamental component of a regionalized neonatal‐perinatal care system.2 Level of care designations are beneficial for several reasons:2

They permit articulation and examination of standards that must be met for provision of specified levels of care;

They facilitate the transfer of patients from one facility to another through common understanding of their relative capabilities and expectations;

They help streamline planning and allocation of resources. History in the GTA As part of the Hospital Services Restructuring Commission (HSRC) deliberations that occurred from 1997–1999, hospitals in the GTA were reviewed with respect to their maternal‐newborn and paediatric services. Final recommendations of the HSRC resulted in a number of GTA hospital closures and removal of paediatric and/or maternal‐newborn services from others. The GTA hospitals that retained paediatric and maternal‐newborn services were mandated to work together under the auspices of the Child Health Network (CHN) for the Greater Toronto Area (disbanded in September 2010) to develop a coordinated regional system of care for mothers, newborns, children and youth. This hospital network included 18 acute care hospitals (across 26 hospital sites) that provided perinatal and NICU services.3 These hospitals were designated to provide a specific level of care with a clearly defined scope of services –– two GTA hospitals were designated “Level III Perinatal Care”, five GTA hospitals were assigned a designation of “Advanced Level II Perinatal Care” (Level II+), while eleven others

CHAPTER 3 MATERNITY HEALTH SERVICE ISSUES


were designated to provide “Level II Perinatal Care”. Those remaining were designated as “Level I Perinatal Care” and provided care for healthy mothers and full‐term infants.3 This report expands beyond the member hospitals of the former CHN to include seven additional hospital sites within the LHINs of the GTA region. This allows for LHIN reporting that is inclusive of all hospital sites providing maternity care. Appropriate Level of Care Research examining the outcomes of babies born at or before 32 weeks’ gestation in Canadian hospitals indicates that outcomes are better when these babies are born at a tertiary care center (i.e., a Level III hospital), even after adjusting for perinatal risk factors.4 Specialist care, staffing levels, the equipment that is available and the avoidance of stress caused by transport after birth have all been suggested as factors that might contribute to this difference.4 Subsequent research has continued to demonstrate that very‐low‐birth‐weight babies have the best survival rates when they are born in hospitals with NICUs that provide a high level of care and have a high patient volume.5 While late preterm infants (born at 34–36 weeks’ gestation) have very low rates of morbidity and mortality compared with early preterm infants, they are at increased risk for a wide range of complications including respiratory distress, temperature instability, hypoglycemia, kernicterus, apnea, seizures and feeding problems when compared with infants born at term.6 Given the increased likelihood that late preterm babies will require NICU care, it is generally recommended that births prior to 36 weeks occur in at least a Level II hospital.


Figure 3.1 Distribution of live births at each level of care, by LHIN of birth




Definition of indicator The distribution of live births at each level of care (Levels I, II, II+, modified III [M3] and Level III), expressed as a percentage of the total number of live births (in a given place and time).

Notes: 1. A complete list of GTA hospital sites and their corresponding level of care can be found in APPENDIX F.

2. Level M3 refers to a Modified Level III. These hospital sites provide care to infants ≥29 weeks’ gestation.

Across the GTA, the majority of live births took place in a Level II hospital (49.0%), followed by about a

quarter (27.5%) in a Level II+ hospital, 14.0% in a Level III hospital and 9.5% in a Level I hospital.

The highest proportion of live births in a Level I hospital occurred in Central East (19.8%).

The scope of services for each level of care designation defines the maximum level of acuity and complexity of mothers and infants who can be cared for by that hospital. All hospitals care for mothers and infants who are healthy (low risk) as well as those who are at the maximum level of acuity and complexity according to their hospital’s level of care designation.

In Ontario, Level III hospitals are located in densely populated urban centres where critical mass supports the need for both specialized and low risk care. Unique to the GTA, each LHIN adjacent to the Toronto Central LHIN has a regional centre providing advanced Level II services (Level II+), which can provide more specialized care than Level II. These Level II+ centres decrease the demand for Level III services and offer care closer to home.


Figure 3.2 Distribution of live births at each level of care, by gestational age at birth




Definition of indicator The distribution of live births at each level of care (Levels I, II, II+ and III), expressed as a percentage of the total number of live births (in a given place and time).

In the GTA in 2009–2010, the proportion of live births that took place in a Level III hospital was highest

among those infants born between 24–27 weeks of gestational age (74.6%) and decreased with increasing gestational age at birth to a low of 12.9% in term live births (≥37 weeks).

From 32 weeks of gestational age onwards, the majority of live births in the GTA occurred in either a Level II+ or Level II hospital, and this proportion increased with increasing gestational age at birth.

Less than a quarter (21.3%) of infants born during a gestational period where survival is extremely low (<24 weeks’ gestation) were born at a Level III centre (26 out of 122 live births). Close to half of infants (48.4%) born at <24 weeks’ gestation were born at a Level II hospital (59 out of 122 live births) and a further 9.8% (12 infants) were born in Level I centres. The reasons why not all live births at <24 weeks are born in a tertiary care centre are likely complex and include a ‘grey zone’ in terms of survival/long‐term outcome, parental wishes, and no clear clinical practice guidelines to guide care providers in a situation that can change almost daily.


Figure 3.3 Distribution of live births 24–36 weeks at each level of care, by gestational age at birth

and fiscal year Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010

Fiscal year Level of care Gestational age

24‐31 weeks (n=735)

32‐33 weeks (n=646)

34‐36 weeks (n=3,864)

III 67.5 23.4 19.4

II / II+ 30.7 73.8 75.5

2005–06

I 1.8 2.8 5.1

24‐31 weeks (n=772)

32‐33 weeks (n=690)

34‐36 weeks (n=4,125)

III 66.3 27.5 19.4

II / II+ 30.7 70.4 74.9

2006–07

I 3.0 2.0 5.6

24‐31 weeks (n=806)

32‐33 weeks (n=730)

34‐36 weeks (n=4,197)

III 62.0 27.5 19.3

II / II+ 34.6 70.3 74.1

2007–08

I 3.3 2.2 6.6

24‐31 weeks (n=747)

32‐33 weeks (n=686)

34‐36 weeks (n=4,310)

III 57.4 28.9 18.9

II / II+ 39.9 69.8 73.9

2008–09

I 2.7 1.3 7.2

24‐31 weeks (n=764)

32‐33 weeks (n=717)

34‐36 weeks (n=4,251)

III 66.8 28.9 19.8

II / II+ 31.0 69.3 73.6

2009–10

I 2.2 1.8 6.6




Notes: 1. A more detailed matrix of levels of care by gestational age groups can be found in APPENDIX G.

The proportion of live births between 24–31 weeks of gestational age that were born in a Level III hospital, which is the optimal level of care for this gestational age decreased between 2005–2006 and 2008–2009 from 67.5% (95% CI: 64.0–70.9) to 57.4% (95% CI: 53.8–61.0), and then increased by 16% in 2009–2010 to 66.8% (95% CI: 63.3–70.1).

In recent years, concern over rising rates of live births <32 weeks born outside of Level III hospitals prompted further study of this issue in the GTA. The 16% increase in the proportion of these births in


the appropriate level of care (i.e., Level III hospital) in the 2009–2010 fiscal year is an important change in direction for this trend and should continue to be monitored.

Among infants between 32–33 weeks of gestational age, the majority were born in a Level II or Level II+ hospital. There was a slight decrease in this proportion over time, from 73.8% (95% CI: 70.3–77.2) in 2005–2006, to 69.3% (95% CI: 65.8–72.7) in 2009–2010. At the same time, the proportion of live births born at 32–33 weeks in Level III hospitals increased slightly from 23.4% (95% CI: 20.2–26.8) in 2005–2006 to 28.9% (95% CI: 25.6–32.3) in 2009–2010.

Maternal Inter‐hospital Transfers Maternal transfers between hospitals occur for both clinical reasons and reasons related to the availability of hospital resources. Maternal transfers to a hospital that provides a higher level of care are usually driven by concerns about maternal condition or the anticipated gestational age or condition of the newborn at birth.7 Transfers in the opposite direction, from a hospital with a higher level of care designation to one with a lower level, include transfers back to the original hospital of care once a high risk situation has resolved as well as transfers of low‐risk mothers in order to make beds available within a high‐risk centre for high risk mothers.7 The availability of beds and human resources are often the reason for maternal transfers between hospitals with similar levels of care.7

Decisions to transfer involve consideration of the clinical issues, the expertise and resources available at both hospitals and travel conditions.8 The availability of skilled accompaniment during transfer may also influence this decision.7 Given the evidence of improved outcomes for preterm babies born before 30‐32 weeks when their mothers are transferred to a Level III hospital prenatally,4 it has been suggested that in utero transfer should be a primary goal whenever the benefits of transfer outweigh the risks.9

Even when the clinical benefits of maternal transfer appear obvious, women may be hesitant to be transferred to what is often a larger, unfamiliar hospital. This reluctance may be due to anxiety about increased travel time, fear of invasive technology, and the potential family disruption and financial burden.10 The availability of affordable accommodation for parents anticipating a prolonged stay away from their home community may address some of these concerns.4 It has also been noted that care providers should be attentive to the emotional needs of women who require maternal transfer.9


Figure 3.4 Inter‐hospital maternal transfer profile, by level of care of receiving hospital


Level of care of ‘receiving‘ hospital

Level I Level II Level II+ Level III

TOTAL

% % % % %

Level I ‐‐ 14.0 41.9 9.5 13.1

Level II ‐‐ 46.5 25.8 46.6 43.7

Level II+ ‐‐ 11.5 ‐‐ 24.6 21.1

Level III ‐‐ 11.5 ‐‐ 1.8 4.4

Level of care of ‘sending’ hospital

Out of region 27.8 16.6 16.1 17.6 17.7

TOTAL 100.0 100.0 100.0 100.0 100.0



Definition of indicator The distribution of level of care of ‘sending’ hospital (i.e., hospital transferred from), expressed as a percentage of the total number of maternal inter‐hospital transfers resulting in a delivery in one of the five LHINs in the Greater Toronto Area (GTA) in 2009–2010.

Notes: 1. Hospitals with no obstetrical services (NOS) do not have a level of care assigned. Fewer than 5 women were transferred from a NOS hospital in 2009–2010. These records are excluded from this analysis.

2. This figure only includes Ontario residents who were transferred into a GTA hospital. Residents from other Canadian provinces/territories or from other countries are excluded.

3. Planned home births are excluded from this figure. 4. Out‐of‐region maternal transfers do not have a level of care assigned as this information is not

consistently available in the database. 5. Estimates based on a cell size of <5 have been suppressed.

There were a total of 412 maternal inter‐hospital transfers resulting in a delivery that occurred in a GTA hospital in 2009–2010, of which 73 (17.7%) were from a hospital outside of the GTA LHIN Region. The remaining 339 maternal transfers (82.3%) were between GTA hospital sites.

Among the 284 maternal transfers that were received by a Level III GTA hospital for delivery in 2009–2010, the majority were transferred from a Level II (46.6%) or Level II+ (24.6%) GTA hospital. About 9% (9.5%) were transferred from a Level I GTA hospital and 17.6% were transferred from a hospital outside the GTA.

Among the 73 maternal transfers from a hospital outside the GTA LHIN Region into a GTA hospital, 50 (68.5%) were transferred into a Level III GTA hospital for delivery (percentage not shown in figure above).


Figure 3.5 Proportion of maternal inter‐hospital transfers to a higher, equivalent or lower level of care, by level of care of sending hospital Greater Toronto Area (GTA) LHIN Region, 2009–2010



Definition of indicator The number of maternal inter‐hospital transfers to a higher, equivalent or lower level of care, expressed as a percentage of the total number of women who were transferred to another hospital to give birth (in a given place and time).

Notes: 1. Hospitals with no obstetrical services (NOS) do not have a level of care assigned. Fewer than 5 women were transferred from a NOS hospital in 2009–2010. These records are excluded from this analysis.

2. Women who were transferred from a hospital from outside the GTA LHIN region are excluded since the information on level of care for the transferring hospital is not consistently available in the database.

3. Planned home births are excluded from this figure.

Among the 339 maternal inter‐hospital transfers between GTA hospital sites, 262 (77.1%) were transferred to a hospital with a higher level of care, 48 (14.3%) to a hospital with the same level of care and 29 (8.6%) were transferred to a hospital with a lower level of care designation.

Of the 18 women who were transferred from a Level III hospital to give birth, the majority were transferred to a hospital with a lower level of care designation to give birth 13 (72.2%).


References

1. Child Health Network (CHN). Niday Perinatal Database for the GTA: Fifth Annual Statistical Report 2007/2008 [Internet].

Toronto, Ontario: CHN; 2008 [cited 23 Apr 2010]. Available from: https://www.nidaydatabase.com/info/pdf/Niday_07‐08_Final‐updated.pdf.

2. Canadian Paediatric Society (CPS). Fetus & Newborn Committee. Levels of neonatal care [Internet]. Paediatric Child Health 2006;11(5):303–6 [cited 23 Apr 2010]. Reference No.: FN06‐02. Available from: http://www.cps.ca/english/statements/FN/fn06‐02.htm.

3. Child Health Network (CHN) for the Greater Toronto Area. What is the CHN [Internet]? [cited 20 Apr 2010]. Available from: http://www.childhealthnetwork.com/chn/what.php.

4. Chien LY, Whyte R, Aziz K, Thiessen P, Matthew D, Lee SK. Improved outcome of preterm infants when delivered in tertiary care centers. Obstet Gynecol 2001;98(2):247–52.

5. Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in very‐low‐birth‐weight infants. NEJM 2007;356(21):2165–75.

6. Raju TNK, Higgins RD, Stark AR, Leveno KJ. Optimizing Care and Outcome for Late‐Preterm (Near‐Term) Infants: A Summary of the Workshop Sponsored by the National Institute of Child Health and Human Development. Pediatrics 2006;118(3):1207–14.

7. Child Health Network (CHN). Niday Perinatal Database for the GTA: Fifth Annual Statistical Report 2007/2008 [Internet]. Toronto, Ontario: CHN; 2008 [cited 23 Apr 2010]. Available from: https://www.nidaydatabase.com/info/pdf/Niday_07‐08_Final‐updated.pdf.

8. Solimano A, Littleford J, Ling E, O’Flaherty D, Osiovich H, Vanderpas E. ACoRN, Acute Care of at‐Risk Newborns. Edmonton: McCallum Printing Group, 2009.

9. Wilson AK, Martel MJ, Arsenault MY, et al. Maternal transport policy. J Obstet Gynaecol Can 2005;27(10):956–63.

10. Kitchen W, Ford G, Orgill A, et al. Outcomes of extremely low birth‐weight infants in relation to the hospital of birth. Aust N Z J Obstet Gynaecol 1984;24:1–5.


Type of Care Provider at Delivery Pregnant women in Ontario have options when choosing a care provider for birth. These include obstetricians, family practitioners and midwives. The vast majority of births, however, are attended by obstetricians.1 It has been estimated that up to 60% of pregnant women could be eligible for less interventional practices (labour and birth that proceeds without induction, use of instruments, surgery or anesthesia/analgesia).2 This would include women who do not have health problems prior to pregnancy, have no obstetrical/medical complications during pregnancy, are carrying a singleton baby at term in a vertex presentation and go into labour spontaneously.2 Midwifery services are specifically designed for women with low‐risk pregnancies; however, in 2006–2007, midwives were the primary care provider at the time of birth for only 6.2% of women with low‐risk pregnancies in Ontario.1 There is an impending shortage of health care professionals providing obstetrical care in Canada.3 Fewer obstetricians than family physicians are trained each year, and family physicians are increasingly opting out of maternity care. Exploration of alternate models of inter‐professional care to improve accessibility and provide more access to the right care at the right place by the right care provider has been recommended.3

CHAPTER 4 BIRTH


Figure 4.1 Distribution of type of health care provider who attended the hospital birth, by LHIN of





The distribution of type of health care provider who attended the hospital delivery, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time).

Notes: 1. ‘Other’ includes nurse practitioners and care providers whose type was unspecified. 2. Midwifery‐attended home births are not included in this figure. See Figure 1.7 for the number of

midwifery‐attended home births in 2009–2010.

The majority of women in all GTA LHINs had an obstetrician attending their hospital delivery.

The proportion of women whose primary care provider was a family physician at the time of their hospital delivery ranged from a low of 3.9% among women who delivered in Central LHIN to a high of 10.2% in Central East LHIN.

Midwives were the primary care provider at three percent of hospital births in the GTA in 2009–2010.

When complications arise during labour that require a midwife or family physician to transfer care to an obstetrician, the midwife or family physician will often continue to attend the birth. The new BORN maternal child database that will be implemented in the fall of 2011 will capture information on both the type of health care provider who is primarily responsible at the onset of the intrapartum period and the type of health care provider who is most responsible at the time of birth.


Fetal Surveillance The rationale for fetal surveillance in labour is that timely detection of changes in the fetal heart rate or patterns could signal potential oxygenation problems. Recognizing these changes early would give care providers time to intervene to prevent fetal or newborn morbidity or mortality. While there is little disagreement about the need for some form of fetal surveillance during labour, the efficacy of methods, frequency and clinical meaning of results continue to be debated. To address some of these controversies, the authors of the 2007 guidelines on fetal health surveillance from the Society of Obstetricians and Gynaecologists of Canada (SOGC)4 did an extensive literature review and concluded:

Electronic fetal monitoring (EFM) compared with intermittent auscultation (IA) has not been shown to improve long‐term fetal or neonatal outcomes as measured by a decrease in morbidity or mortality

Continuous EFM during labour is associated with a reduction in neonatal seizures, but with no significant differences in long‐term sequelae, including cerebral palsy, infant mortality, and other standard measures of neonatal well being

“EFM is associated with an increase in interventions, including cesarean section, vaginal operative delivery and the use of anesthesia” (p. S27).4

Despite these conclusions, EFM is used extensively in clinical practice in Canada5 and there are a variety of reasons for why clinicians, institutions and systems are hesitant to change.6 If groups or institutions do intend to change fetal surveillance practice, there are resources to guide the change and evaluation.7 Audit and feedback is a strategy that can be used to try and modify practice. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.8 Data on use of fetal surveillance can be extracted from the BORN system monthly, quarterly or yearly and presented to managers, clinicians and regional groups as one strategy to help support change.


Figure 4.2 Fetal surveillance methods during labour, by LHIN of birth





The distribution of types of fetal surveillance used during labour (no monitoring, auscultation only, auscultation and electronic fetal monitoring [EFM], EFM only), expressed as a percentage of the total number of women who had spontaneous onset of labour or induced labour (in a given place and time).

Notes: 1. For this indicator, EFM is comprised of the following values: EFM admission strip, intrapartum EFM (external) and intrapartum EFM (internal).

Across the GTA LHIN Region, 70.6% of women received only electronic fetal monitoring (EFM) during labour. A further 21.1% of women were monitored with auscultation in combination with EFM. Taken together, 91.7% of women had EFM at some time during their labour.

The proportion of women who received auscultation only during their labour was 6.5% across the GTA, ranging from 4.0% in Central West to 9.2% in Mississauga Halton.

Among low‐risk women (defined as women with a singleton live birth in cephalic presentation at 37–41 weeks’ gestation, with spontaneous onset of labour, no previous cesarean deliveries, no maternal medical problems, and no obstetrical or intrapartum complications), 63.2% received EFM alone and a further 24.1% received EFM in combination with auscultation (data not shown).

The rate of auscultation only among low‐risk women was higher than in the overall obstetric population (10.8% compared with 6.5%, respectively). Across the GTA, the rate of auscultation only


among low‐risk women was 6.9% in Central West, 15.8% in Mississauga Halton, 16.4% in Toronto Central, 7.5% in Central and 9.8% in Central East (data not shown in figure).


Figure 4.3 Rate of auscultation only for fetal surveillance during labour, by fiscal year Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010




The number of women who received auscultation only for fetal surveillance during labour, expressed as a percentage of the total number of women who had spontaneous onset of labour or induced labour (in a given place and time). For this analysis, both the overall distribution and the distribution among low‐risk women are presented. Low‐risk women were defined as women with a singleton live birth in cephalic presentation at 37–41 weeks’ gestation, with spontaneous onset of labour, no previous cesarean deliveries, no maternal medical problems, and no obstetrical or intrapartum complications.

Between 2005–2006 and 2009–2010, the proportion of women who received auscultation only for

fetal surveillance during labour decreased slightly from 7.9% (95% CI: 7.7–8.2) to 6.5% (95% CI: 6.3–6.7).

The rate of auscultation only among low‐risk women was higher than in the overall obstetric population, but also decreased over the five fiscal years from 12.4% (95% CI: 11.9–12.9) in 2005–2006 to 10.8% (95% CI: 10.4–11.3) in 2009–2010.


Induction of Labour Induction of labour is indicated in situations where the risks to the mother or the fetus of continuing the pregnancy outweigh the benefits.9 Severe pre‐eclampsia and non‐reassuring fetal status are two examples of such situations.9 Induction of labour is contraindicated whenever there is a contraindication to labour or to vaginal birth – for example, a previous classical uterine incision.9 One of the main risks of induction of labour is an increased risk of cesarean section, particularly among nulliparous women.10–13 Although cervical ripening prior to induction of labour lowers the risk of cesarean section when compared to induction of labour with oxytocin alone,14 women who require cervical ripening prior to induction of labour appear to have the greatest risk of cesarean section.11,13 Other risks of induction of labour include uterine hyperstimulation causing fetal compromise, increased risk of uterine rupture if there is a history of cesarean section, and failure to establish labour.15 Induction of labour can also entail increased health care costs.16 For all of these reasons, elective induction of labour (i.e., induction that is solely for the convenience of the woman or her care provider) is not recommended. According to the Canadian Perinatal Health Report, the rate of labour induction in 2005–2006 was 21.8 per 100 hospital births in Canada and 20.3 in Ontario.17 The single most common indication for induction of labour is post‐dates pregnancy. Evidence from randomized controlled trials suggests that a policy of labour induction after 41 weeks’ gestation is associated with a slightly lower risk of perinatal death when compared to expectant management.18 Both early ultrasound (to avoid inaccurate dating) and stripping or sweeping the membranes (to promote spontaneous labour) are potential strategies to reduce the rates of induction for this indication.19,20 The Society for Obstetricians and Gynaecologists of Canada recommends that women be offered induction at 41+0 to 42+0 weeks.21 The new BORN maternal child database that will be implemented in the fall of 2011 is adding a variable on Bishop’s Score. This will allow hospitals, care providers and BORN to have a much better understanding of the relationship between the status of the cervix prior to induction, cervical ripening and induction and delivery type and outcome.


Figure 4.4 Distribution of type of labour, by LHIN of birth





The number of women with spontaneous onset of labour, induced labour or no labour, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time).

Across the GTA LHIN Region, 61.4% of women went into spontaneous labour, with only slight variation across the five LHINs. The rate of labour induction was 23.0% in the GTA and 25.2% in the province.


Figure 4.5 Rate of labour induction, by fiscal year




Definition of indicator The number of women who had labour induction, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time). For this analysis, both the overall rate of labour induction and the rate among standardized nulliparous women are presented. Standardized nulliparous women were defined as nulliparous women (i.e., parity = 0) with a singleton live birth in cephalic presentation at term gestation (>37 weeks).

In the overall obstetrical population, the rate of labour induction showed little change between 2005–

2006 and 2009–2010, going from 22.0% (95% CI: 21.7–22.3) to 23.0% (95% CI: 22.7–23.3).

Among those meeting the definition for standardized nulliparous women, the rates of labour induction were, on average, approximately 29% higher than in the overall obstetrical population. Over the five fiscal years, the rate of labour induction increased in this subgroup from 28.1% (95% CI: 27.6–28.7) in 2005–2006 to 30.6% (95% CI: 30.0–31.1) in 2009–2010.


Figure 4.6 Rate of labour induction, by hospital level of care Greater Toronto Area (GTA) LHIN Region, 2009–2010




The number of women who had labour induction, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time). For this analysis, both the overall rate of labour induction and the rate among standardized nulliparous women are presented. Standardized nulliparous women were defined as nulliparous women (i.e., parity = 0) with a singleton live birth in cephalic presentation at term gestation (>37 weeks).

The rate of labour induction showed some variation by the hospital level of care designation.

Approximately 22% of women who gave birth in a Level II/II+ hospital were induced (21.9% and 22.3%, respectively). Approximately 26% of women who gave birth in Level I or Level III hospital underwent labour induction.

Rates of labour induction among those who met the definition for standardized nulliparous women were consistently higher than in the overall obstetrical population across all hospital levels of care.


Figure 4.7 Proportion of women who underwent labour induction, by gestational age at birth





The number of women who had labour induction, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time).

The proportion of women who underwent labour induction was lowest among women who delivered

at ≤33 completed weeks of gestation (14.6%) and highest among the women whose pregnancies reached 41 weeks’ gestational age or greater (60.7%).


Figure 4.8 Indication for induction of labour


Indication Number of women

(15,550)

Percent (%) of women who had induction of

labour

Post dates 5,866 37.7

Other – maternal 1,705 11.0

Diabetes 1,669 10.7

Elective 1,407 9.0

PROM 1,367 8.8

Pre‐eclampsia 943 6.1

Maternal obstetrical conditions 795 5.1

Intra‐uterine growth restriction/Small for gestational age

783 5.0

Other – fetal 743 4.8

Oligohydramnios 466 3.0

Poor biophysical score 292 1.9

Large for gestational age 269 1.7

Multiple gestation 184 1.2

Pre‐existing maternal medical conditions 194 1.2

Non‐reactive NST 154 1.0




The number of women with one or more indications for labour induction, expressed as a percentage of the total number of women who had labour induction (in a given place and time).

Notes: 1. More than one indication for labour induction is permitted in the database; therefore, percentages in this figure do not add up to 100%.

Across the GTA, the leading indication for labour induction was post‐dates pregnancy (37.7%),

followed by other–maternal reason (11.0%) and diabetes (10.7%). Post‐dates pregnancy was the leading indication for labour induction in each GTA LHIN in 2009–2010.

Note that the new BORN maternal child database that will be implemented in the fall of 2011 will attempt to reduce the reliance on “Other” as a category for indication for induction by providing more granular options for data entry.


Figure 4.9 Proportion of women who were <41 weeks of gestational age at delivery among women who were induced and had a post dates indication for induction of labour, by LHIN of birth Greater Toronto Area (GTA) LHIN Region, 2009–2010




The number of women who were less than 41 weeks of gestational age at delivery, expressed as a percentage of the total number of women who had labour induction and an indication for induction of ‘post‐dates pregnancy’ (in a given place and time).

Across the GTA in 2009–2010, 18.4% of women (1,079 out of 5,866 women) who were induced and

had a documented indication of post‐dates pregnancy were <41 weeks of gestational age at the time they gave birth. Across the province, a similar proportion of women with a post‐dates indication for induction were <41 weeks’ gestation at delivery (18.0%).

Although there was considerable variability across the GTA LHINs in the proportion of women who were <41 weeks at the time of birth who were induced with a documented indication of post‐dates pregnancy, none were below 40 weeks’ gestation.


Type of Delivery

Operative Vaginal Delivery Operative vaginal delivery (vaginal delivery assisted by the use of vacuum and/or forceps) is performed when maternal or fetal concerns during the second stage of labour necessitate intervening to expedite the delivery of the baby.22,23 The most common indications for operative vaginal birth include abnormal fetal heart rate, maternal cardiovascular complications and inadequate progress.22 The overall rates of operative vaginal delivery decreased slightly in Canada between 1995–1996 and 2005–2006, from 16.3 to 14.8 per 100 hospital deliveries. Over the same time period, the rate of forceps delivery decreased, while the rate of vacuum extraction increased.23 The Society for Obstetricians and Gynaecologists of Canada recommends several strategies for reducing the need for operative vaginal delivery. These include one‐to‐one support for women during labour, partogram use, oxytocin use when labour is not progressing adequately, and delayed pushing among women using epidural pain management.22

Cesarean Delivery Canadian cesarean delivery rates increased by 45% in the last decade, from 17.6% in 1995–1996 to 25.6% in 2005–2006, with increases observed for both repeat cesarean delivery and primary cesarean delivery.24 Over one‐third (35.4%) of Canadian women who undergo cesarean delivery are having a repeat cesarean.24 Thus, preventing rising cesarean rates will depend, in part, on preventing primary cesarean delivery where possible. The increase in primary cesarean delivery has been attributed to changes in maternal characteristics (increases in maternal age and pre‐pregnancy body mass index, and reductions in parity), changes in obstetrical practice (increasing use of electronic fetal monitoring, cesarean delivery for breech presentation, labour induction and epidural anesthesia, and reduced use of midpelvic forceps)25 and an increase in maternal request for cesarean delivery.26,27 Cesarean delivery is not without risks – it has been associated with both immediate (e.g., anesthetic complications, cardiac arrest, venous thromboembolism)28 and later (e.g., postpartum hospital readmission, pelvic injury/wounds, major puerperal infection)29 risk of complications; therefore, the rising rate of cesarean birth is of concern. Robson’s Ten‐Group Classification System To address concerns over rising rates of cesarean delivery and provide a mechanism for audit and response, a classification system that examines cesarean rates within mutually exclusive groups of women with particular obstetric characteristics was proposed in 2001.30 Briefly, Robson’s classification system groups women in the obstetric population according to plurality, fetal presentation, parity, obstetric history (i.e., previous cesarean delivery), course of labour and delivery and gestational age at delivery, providing clinically relevant categories for analyzing and reporting rates of cesarean delivery. The central tenet of this system is that in certain clinical situations, delivery by cesarean is appropriate –– a fact that is obscured when the overall rate of cesarean delivery is examined in isolation.30 In the Robson classification system, the overall rate of cesarean is presented as a composite of individual rates from ten groups. This permits not only examination of the group‐specific rates to determine their appropriateness, but also demonstrates how the overall rate of cesarean is affected by both the magnitude of the individual rates and the relative size of each of the groups (i.e., the background


composition of the obstetrical population), thus identifying the groups that make the greatest contribution to the overall rate of cesarean delivery.30 Those groups that contribute most substantially to the overall rate can then be examined more carefully. By using core obstetrical information that is routinely collected and a system of classification that is simple and easy to implement,30 the Robson classification system can be used to facilitate comparisons across time and clinical settings, since it accounts for the background composition of the obstetrical population, which is likely to differ across time and place. This tool has recently been used to make international comparisons in cesarean rates. In multicentre studies in Latin America (120 hospitals in eight countries)31 and North America, Europe, Australia and New Zealand (nine hospitals in nine countries),32 the classification system was easily implemented across different countries, hospital sites and data collection systems, suggesting it is a robust and useful tool for ongoing surveillance.31


Figure 4.10 Rate of operative vaginal delivery, by LHIN of birth





The number of women who had a vaginal delivery that was assisted by means of forceps and/or vacuum extraction, expressed as a percentage of the total number of women who had a vaginal delivery (in a given place and time). For this analysis, both the overall rate of operative vaginal delivery and the rate among women who met the definition for standardized nulliparous women are presented. Standardized nulliparous women were defined as nulliparous women (i.e., parity = 0) with a singleton live birth in cephalic presentation at term gestation (>37 weeks).

Across the GTA LHIN Region in 2009–2010, the rate of operative vaginal delivery was 15.2%, slightly

higher than the background rate for Ontario (13.6%).

Among those women with a vaginal birth meeting the definition for standardized nulliparous women, the rates of operative vaginal delivery were, on average, approximately 59% higher than in the overall obstetrical population.


Figure 4.11 Rate of operative vaginal delivery, by fiscal year Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010




The number of women who had a vaginal delivery that was assisted by means of forceps and/or vacuum extraction, expressed as a percentage of the total number of women who had a vaginal delivery (in a given place and time). For this analysis, both the overall rate of operative vaginal delivery and the rate among women who met the definition for standardized nulliparous women are presented. Standardized nulliparous women were defined as nulliparous women (i.e., parity = 0) with a singleton live birth in cephalic presentation at term gestation (>37 weeks).

The overall rate of operative vaginal delivery decreased by 16% over this five‐year period, going from

18.1% (95% CI: 17.7–18.4) of women with a vaginal birth in 2005–2006 to 15.2% (95% CI: 14.8–15.5) in 2009–2010.

Among those meeting the definition for standardized nulliparous women, the rates of operative vaginal delivery were higher than in the overall obstetrical population, but decreased by a similar magnitude across the five fiscal years.


Figure 4.12 Rate of cesarean delivery, by fiscal year





The number of cesarean deliveries, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time).

There was a small increase in the rate of cesarean delivery in the GTA between 2005–2006 and 2009–2010, from 28.1% (95% CI: 27.8–28.5) to 29.4% (95% CI: 29.1–29.7).


Figure 4.13 Rate of cesarean delivery, by LHIN of birth






Across the GTA LHIN Region, the rate of cesarean delivery in 2009–2010 was 29.4%, marginally higher

than the provincial rate of 28.3%.

The rate of cesarean was lowest in Mississauga Halton (25.8%) and highest in Toronto Central (32.3%).


Figure 4.14 Rate of cesarean delivery, by hospital level of care Greater Toronto Area (GTA) LHIN Region, 2009–2010





The rate of cesarean showed some variation by the hospital level of care designation, in a slight “J‐shaped” pattern. The lowest rate was among women who gave birth in a Level II centre (27.3%), and the highest rate of cesarean was among women who gave birth in a Level III centre (36.4%). The high rate of cesarean among women who gave birth in a Level III hospital is expected since these hospitals provide care to a higher frequency of women with high‐risk pregnancies.

Within each level of care designation, the rate of cesarean delivery has fluctuated over the past five fiscal years and rose slightly between 2005–2006 and 2009–2010 within most levels of care (Level I from 30.5% to 30.5%; Level II from 26.0% to 27.3%; Level II+ from 27.5% to 29.2%; Level III from 35.7% to 36.4%) (data not shown in figure).

BORN Ontario Perinatal H

ealth Report 2009–2010 – G

reater Toronto Area (GTA

) LH

IN Region

74

Figure 4.15

Rate of cesarean

delivery, b

y Robson classification groups

Greater Toronto Area (GTA

) LH

IN Region, 2005–2006 and 2009–2010

2005–2006

2009–2010

A

B

C

D

E A

B

C

D

E

Robson classification group

# of

cesarean

deliveries

Total # of

deliveries

Rate of

cesarean

(A*100/B)

Relative size of

group

(B*100/68,581)

Contribution to

overall rate

(A*100/68,581)

# of

cesarean

deliveries

Total # of

deliveries

Rate of

cesarean

(A*100/B)

Relative size of

group

(B*100/71,732)

Contribution to

overall rate

(A*100/71,732)

1

Nulliparous, singleton, cep

halic, ≥37 weeks,

spontaneo

us labour

2,692

16,925

15.9

24.7

3.9

2,739

17,713

15.5

24.7

3.8

2

Nulliparous, singleton, cep

halic, ≥37 weeks,

induced labour or cesarean

before labour

3,037

7,839

38.7

11.4

4.4

3,456

9,024

38.3

12.6

4.8

(2a)

Induced labour

2,208

6,979

31.6

10.2

(3.2)

2,620

8,188

32.0

11.4

(3.7)

(2b)

Cesarean before labour

829

829

100.0

1.2

(1.2)

836

836

100.0

1.2

(1.2)

3

Multiparous, singleton, cephalic, ≥37 weeks,

no previous cesarean, spontaneo

us labour

489

16,404

3.0

23.9

0.7

486

18,396

2.6

25.6

0.7

4


no previous cesarean, induced labour or

cesarean

before labour

870

5,944

14.6

8.7

1.3

764

6,620

11.5

9.2

1.1

(4a)

Induced labour

330

5,369

6.1

7.8

(0.5)

371

6,227

6.0

8.7

(0.5)

(4b)


540

540

100.0

0.8

(0.8)

393

393

100.0

0.5

(0.5)

5


previous cesarean

5,277

6,253

84.4

9.1

7.7

7,286

8,404

86.7

11.7

10.2

(5a)

Spontaneous labour

816

1,636

49.9

2.4

(1.2)

1,090

2,057

53.0

2.9

(1.5)

(5b)

Induced labour

76

217

35.0

0.3

(0.1)

64

215

29.8

0.3

(0.1)

(5c)


4,371

4,371

100.0

6.4

(6.4)

6,132

6,132

100.0

8.5

(8.5)

6

Nulliparous, singleton, breech

1,361

1,456

93.5

2.1

2.0

1,544

1,631

94.7

2.3

2.2

7

Multiparous, singleton, breech

1,017

1,126

90.3

1.6

1.5

1,218

1,333

91.4

1.9

1.7

8

Multifetal pregnancy

714

1,151

62.0

1.7

1.0

910

1,350

67.4

1.9

1.3

9

Singleton, transverse or oblique lie

404

479

84.3

0.7

0.6

357

439

81.3

0.6

0.5

10

Singleton, cep

halic, <37 weeks

931

3,364

27.7

4.9

1.4

1,056

3,711

28.5

5.2

1.5

All others with m

issing inform

ation on presentation,

parity, gestational age, type of labour or previous

cesarean

2,513

7,640

32.9

11.1

3.7

1,270

3,111

40.8

4.3

1.8

TOTA

L POPULA

TION

19,305

68,581

28.1

100.0

28.1

21,086

71,732

29.4

100.0

29.4

Data source

BORN Ontario (Niday Perinatal D

atabase), 2005–2006 and 2009–2010

Local H

ealth Integration Network (LH

IN) based on hospital of birth


The number of cesarean deliveries, expressed

as a percentage of the total number of women

who had a live birth or stillbirth (in a given

place and tim

e). For this

analysis, rates of cesarean are calculated in each of 10 categories of the Robson classification system.30Records with m

issing inform

ation on the component

variables were included

in a separate category.


Group 5 (multiparous women who had at least one previous cesarean delivery, with a singleton in cephalic presentation at greater than or equal to 37 weeks’ gestation) made the largest contribution to the overall rate of cesarean delivery in 2009–2010. Although this group accounted for 11.7% of the total obstetrical population (8,404/71,732), it had the largest absolute number of cesarean deliveries, accounting for 34.6% of all cesarean deliveries (7,286/21,086). The relative size of this group of the obstetric population has increased in the GTA in recent years –– between 2005–2006 and 2009–2010, the relative size of Group 5 increased from 9.1% to 11.7%, an increase of 28.6%.

Group 2 (nulliparous women with a singleton in cephalic presentation at greater than or equal to 37 weeks’ gestation who have had induction of labour or no labour) made the next largest contribution to the overall rate of cesarean delivery in 2009–2010. Group 2 contained 12.6% of the obstetric population (9,024/71,732) and had the second largest absolute number of cesarean deliveries, which accounted for 16.4% (3,456/21,086) of all cesarean deliveries. Group 2 differs from Group 1 only with respect to course of labour (the latter experience spontaneous onset of labour). Nevertheless, the rate of cesarean delivery in Group 2 is more than twice as high as the rate in Group 1 (38.3% versus 15.5%, respectively). The relative size of Group 2 in the obstetric population has increased slightly in the GTA from 11.4% in 2005–2006 to 12.6% in 2009–2010, an increase of 10.5%.

Group 1 (nulliparous women with a singleton in cephalic presentation at greater than or equal to 37 weeks’ gestation who have spontaneous labour) made the third largest contribution to the overall rate of cesarean delivery in 2009–2010. Group 1 contained 24.7% of the obstetric population (17,713/71,732) and had the third largest absolute number of cesarean deliveries, which accounted for 13.0% (2,739/21,086) of all cesarean deliveries.

Together, the contribution of the three groups presented above (Robson Groups 1, 2 and 5) accounted for more than half (63.9%) of the overall rate of cesarean, 49.0% of the total obstetrical population and 63.9% of the total number of cesarean deliveries in 2009–2010.

In the GTA LHIN Region in 2009–2010, Robson Groups 1 and 3 (comprised of women with a singleton in cephalic presentation at greater than or equal to 37 weeks’ gestation and spontaneous labour who were nulliparous or multiparous, respectively) accounted for close to half of the obstetric population. These two groups comprise a similar relative size; however the rate of cesarean in Group 1 (15.5%) is more than five times higher than the rate in Group 3 (2.6%). This is reflected in the contribution to the overall rate of cesarean –– 3.8% in Group 1 and 0.7% in Group 3.

Robson Groups 6 through 9 represent subgroups of the obstetrical population with very high rates of cesarean (range: 67.4% to 94.7% in the GTA in 2009–2010); however, collectively, they make a relatively small (19.4%) contribution to the overall rate of cesarean.

Between 2005–2006 and 2009–2010 in the GTA LHIN Region, there was an improvement in the complete capture of information for the component variables required for assigning a Robson classification group. The relative size of the group of records with missing information on one or more component variables decreased from 11.1% to 4.3%. There was also a corresponding decrease in the contribution of this group to the overall rate of cesarean from 3.7% to 1.8%. This is a very important improvement in data quality that will increase the utility of the Robson classification. Nevertheless, it is important to recognize that the accuracy of the rates, relative sizes and contribution of each group to the overall cesarean rate is adversely impacted by missing information.


Elective Repeat Cesarean Delivery Although most women who have had a previous cesarean delivery are candidates for a trial of labour and vaginal birth (vaginal birth after cesarean – VBAC) in a subsequent pregnancy,33,34 women may ultimately undergo an elective repeat cesarean delivery for a number of reasons including medical or obstetrical contraindication to vaginal delivery, health care provider or institution preference, and maternal preference based on consideration of risks and benefits of VBAC versus elective repeat cesarean delivery.33 A 2009 study in the United States of 13,258 elective repeat cesarean deliveries of singletons at term gestation found that more than one in three (35.8%) were performed at early term gestation (i.e., 37–38 weeks) and neonates delivered at 37 and 38 weeks had significantly higher rates of adverse neonatal outcomes (such as respiratory complications and sepsis) compared with those delivered at 39 weeks.35 In a 2010 Italian study of more than 13,329 elective repeat cesarean deliveries of term singletons, 72% were performed at <39 weeks gestation.36 Significantly increased risk of respiratory morbidity was observed in neonates born at 37 and 38 weeks compared with those born at 39 weeks.36 A recent evidence summary prepared for BORN Ontario based on clinical practice guidelines and original research found that early term delivery (i.e., at 37 or 38 weeks) by elective repeat cesarean is consistently associated with increased neonatal morbidity compared with delivery at 39 weeks, leading the authors of the evidence summary to conclude that elective repeat cesarean deliveries should be delayed until 39 weeks’ gestation for low‐risk women.37

In the fiscal year 2010–2011, BORN Ontario worked with the Champlain Maternal Newborn Regional Program to evaluate rates of elective repeat cesarean birth at term before 39 weeks in low‐risk women who were not in labour across the region as part of a pilot project. Because of the body of evidence to support the need for reducing cesarean delivery before 39 weeks in this population, BORN will be including an indicator for early term delivery (<39 weeks) among elective repeat cesarean deliveries at term in low‐risk women as part of a provincial maternal‐child dashboard. While BORN recognizes there are system, attitudinal, and resource issues associated with changing practice in this area, initiating a process of regular monitoring and feedback regarding practices and outcomes is an important first step in increasing awareness of the issue.


Figure 4.16 Proportion of women with a cesarean delivery performed prior to 39 weeks’ gestation

among low‐risk women having an elective repeat cesarean delivery at term, by LHIN of birth Greater Toronto Area (GTA) LHIN Region, 2009–2010




The number of women with a cesarean delivery performed prior to 39 weeks of gestational age, expressed as a percentage of the total number of women having an elective repeat cesarean delivery at term. Elective repeat cesarean delivery is defined as a cesarean delivery performed before the onset of labour, and in the absence of medical or obstetrical indications for delivery among women with a history of one or more previous cesarean deliveries. For this analysis, the definition included women with a singleton live birth, between 37 and 42 weeks of gestational age, with no maternal medical problems, no obstetrical complications and none of the following indications for the cesarean: cord prolapse, fetal anomaly, intrauterine growth restriction/small for gestational age, large for gestational age, non‐reassuring fetal status, placenta previa, placental abruption, preeclampsia and preterm rupture of membranes.

In the GTA LHIN Region in 2009–2010, the proportion of elective repeat cesarean deliveries at term gestation that were performed prior to 39 weeks was 63.1% (6.5% at 37 weeks and 56.6% at 38 weeks). A further 31.1% were performed at 39 weeks.

Across Ontario, 57.6% of elective repeat cesarean deliveries at term were performed before 39 weeks’ gestation.


Figure 4.17 Rate of episiotomy or 3rd/4th degree perineal laceration, by LHIN of birth





The number of women with an episiotomy or a 3rd or 4th degree perineal laceration, expressed as a

percentage of the total number of women who had a vaginal birth (in a given place and time).

* Between 10% and 30% of records had missing information and were excluded from the calculation of these estimates.

The rate of episiotomy varied considerably by LHIN of birth within the GTA, ranging from a low of about 14% in Central West and Mississauga Halton, to a high of 29.4% in Toronto Central. The rate of episiotomy across the GTA LHIN Region (21.8%) was also higher than the overall provincial rate (18.3%).

In 2009–2010, the rate of 3rd or 4th degree perineal laceration in women who had a vaginal birth was 3.2% in the GTA, ranging between 2.2% and 4.6%.

*


Figure 4.18 Rate of episiotomy or 3rd/4th degree perineal laceration, by fiscal year





The number of women with an episiotomy or a 3rd or 4th degree perineal laceration, expressed as a

percentage of the total number of women who had a vaginal birth (in a given place and time).


The rate of episiotomy was 22.3% (95% CI: 21.9–22.7) in 2005–2006, rose slightly to 23.7% (95% CI: 23.3–24.1) in 2006–2007, and thereafter gradually declined to 21.8% (95% CI: 21.4–22.1) in 2009–2010.

The rate of 3rd or 4th degree perineal laceration was very stable across the five fiscal years.

* **


Figure 4.19 Proportion of women with intrapartum complications, by fiscal year





The number of women with one or more intrapartum complications, expressed as a percentage of the total number of women who had a live birth or stillbirth (in a given place and time).

* Between 10% and 30% of records had missing information and were excluded from the calculation of these estimates. Notes: 1. A complete list of the intrapartum complication categories collected by the database can be found

in APPENDIX H.

In 2009–2010, the most common intrapartum complications were non‐reassuring fetal status (13.5%),

non‐progressive labour/lack of descent/dystocia (7.9%), other (7.8%) and meconium (7.6%).

The proportion of women with one or more intrapartum complications increased from 25.9% (95% CI: 25.5–26.3) in 2005–2006 to 32.5% (95% CI: 32.2–32.9) in 2009–2010.

In 2005–2006, the proportion of records missing this information was 17.3%, decreasing each year to a low of 0.9% in 2009–2010. Comparisons across years should be interpreted with caution due to expansion of data collection activities for this variable over this five‐year period. The rate for 2009–2010 is likely to reflect the most accurate estimate of the proportion of women with one or more intrapartum complications since the data capture was more complete than in the earlier years.

*


Pain Management in Labour and Birth

The majority of women who give birth in Ontario use at least one form of pharmacological pain relief during labour. Epidural anesthesia, narcotics, and nitrous oxide are common options. The choice between these options may be influenced by the clinical situation, the availability of human resources and equipment and by maternal and care provider preferences. Nitrous oxide may be unavailable in hospitals where there is not an adequate scavenging system in place to safely remove residual gases from the birthing room. Narcotics are widely available in hospitals but may be avoided in the latter part of labour because they can cause respiratory depression in the newborn. In hospitals where access to anesthesiology services is limited, rates of epidural use tend to be lower and rates of narcotic and nitrous oxide use tend to be higher. Whenever possible, regional anesthesia (e.g., epidural or spinal) is used for cesarean deliveries rather than general anesthetic in order to allow the mother to be awake for the birth of her baby and prevent transfer of anesthetic agents to the fetus before birth. The rate of epidural use has risen over the last decade in Canada. The proportion of vaginal births in which epidural anesthesia was used rose from 45.4% in 2001–2002 to 55.2% in 2009–2010, and this rate is even higher in Ontario.38,39 Epidurals are generally considered to be the most effective form of pharmacological pain relief in labour, and the Canadian Maternity Experiences Survey found that a high proportion of women who reported using a pain‐management technique to cope with pain during labour rated spinal or epidural as ‘very helpful’.40 While epidurals are considered to be relatively safe, they are associated with a variety of risks. Systematic reviews of the evidence show that epidurals are associated with lower rates of spontaneous vaginal birth,41 higher rates of assisted vaginal birth,41,42 longer duration of labour,41–43

increased use of oxytocin augmentation,43 increased rate of serious perineal lacerations41 and maternal fever.41,43 There is evidence that epidurals are associated with a higher rate of persistent occiput‐posterior presentation at the time of birth but the causal nature of this relationship is debated.44,45 The association between epidural use and cesarean delivery has also been a matter of debate. Although randomized trials suggest there is no increase in the risk of cesarean when epidurals are compared to narcotics, these studies were primarily conducted in settings where active management of labour using high‐dose oxytocin protocols was the standard of care.46 The limited data available suggest that the cesarean section rate is increased when epidurals are used with low‐dose oxytocin, as is the standard practice in many North American settings.46 While the majority of women use pharmacological pain relief at some point in labour, some women prefer to delay or completely avoid the use of pharmacological pain relief. Evidence from randomized controlled trials has shown that continuous support in labour reduces the use of pharmacological management of pain, as well as being associated with higher satisfaction, shorter length of labour, and increased rates of spontaneous vaginal birth.47 The Canadian Maternity Experiences Survey found that after spinal or epidural, the next most commonly used technique reported to be ‘very helpful’ was the use of a bath or shower.40 In order to meet the wide range of preferences of women giving birth, maternity services should ideally be able to offer access to effective methods of both pharmacological and non‐pharmacological pain relief. In many instances, the respectful, caring attitude of health care providers and the ability for a woman to feel an important part of the decision‐making process contribute to her overall sense of safety and well‐being, which is a key part of the concept of ‘comfort’ in labour and birth.48


Figure 4.20 Rates of pharmacologic pain management among women who had a vaginal live birth,

by LHIN of birth Greater Toronto Area (GTA) LHIN Region, 2009–2010




The number of women who had regional anesthesia (epidural, spinal‐epidural combination, spinal) or other analgesia (narcotics, nitrous oxide, pudendal) during labour or birth, expressed as a percentage of the total number of women who had a vaginal live birth (in a given place and time).

Notes: 1. Women may have received more than one type of pain management; therefore, the rates in this figure are not mutually exclusive.

Across the GTA, more than two‐thirds of women (68.8%) who had a vaginal live birth used some form

of regional anesthesia (including epidural, spinal‐epidural combination, spinal) for pain management during labour or birth. This varied from a low of 61.5% in Central West and Central East, to a high of 76.2% in Toronto Central. Across the province, 62.5% of women used regional anesthesia.

About 10% (9.8%) of women in the GTA used another form of analgesia for pain management, including narcotics, nitrous oxide and pudendal. This was considerably lower than the background provincial estimate of 19.8%.

Fifteen percent (14.7%) of women with a vaginal live birth did not use any method of pharmacological pain management (data not shown in figure).



by fiscal year Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010




The number of women who had regional anesthesia (epidural, spinal‐epidural combination, spinal) or other analgesia (narcotics, nitrous oxide, pudendal) during labour or birth, expressed as a percentage of the total number of women who had a vaginal, live birth (in a given place and time).


The proportion of women who had a vaginal live birth who used some form of regional anesthesia

(including epidural, spinal‐epidural combination, spinal) for pain management during labour or birth increased from 63.0% (95% CI: 62.5– 63.4) in 2005–2006 to 68.8% (95% CI: 68.4–69.2) in 2009–2010.

Over the same period of time, the proportion of women who used another form of analgesia for pain management, including narcotics, nitrous oxide and pudendal decreased from 13.9% (95% CI: 13.6–14.2) to 9.8% (95% CI: 9.5–10.1).



by hospital level of care Greater Toronto Area (GTA) LHIN Region, 2009–2010




The number of women who had regional anesthesia (epidural, spinal‐epidural combination, spinal) or other analgesia (narcotics, nitrous oxide, pudendal) during labour or birth, expressed as a percentage of the total number of women who had a vaginal live birth (in a given place and time).


The proportion of women who received regional anesthesia for pain management during labour or birth was lowest in Level I hospital sites (54.9%) and rose with increasing hospital level of care to a high of 83.2% in Level III hospitals.

The proportion of women who used some other form of analgesia for pain management (i.e., narcotics, nitrous oxide, pudendal) was highest in Level I hospitals (31.0%) and Lowest in level III hospitals (2.2%).

Level I hospitals had the highest proportion of women with a vaginal live birth who did not use any pharmacological pain management (17.7% – not shown in figure). This decreased with increasing level of care to 10.3% in Level III hospitals.


Figure 4.23 Rates of pharmacologic pain management among women who had a cesarean live

birth, by LHIN of birth Greater Toronto Area (GTA) LHIN Region, 2009–2010




The number of women who had epidural, spinal, spinal‐epidural combination or general anesthesia for pain management during cesarean delivery, expressed as a percentage of the total number of women who had a cesarean live birth (in a given place and time).


Among women who had a live birth delivered by cesarean, the most commonly used form of pain management was spinal (63.9%), followed by epidural (31.1%).

The proportion of women who received a general anesthetic was 3.3% in the GTA LHIN Region in 2009–2010, corresponding to an absolute number of 679 women. Among these women, the majority (512 women, or 75.4%) had an unplanned cesarean delivery.



birth, by fiscal year Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010






Rates of pharmacologic pain management among women who had a live birth delivered by cesarean showed slight variation between 2005–2006 and 2009–2010. The proportion of women who received epidural decreased from 35.4% (95% CI: 34.7–36.1) to 31.1% (95% CI: 30.5–31.7) over this time period, while the proportion who received spinal increased from 57.9% (95% CI: 57.2–58.6) to 63.9% (95% CI: 63.3–64.6).



birth, by hospital level of care Greater Toronto Area (GTA) LHIN Region, 2009–2010






The proportion of women who received a general anesthetic for their cesarean delivery was highest in Level I hospitals.


Figure 4.26 Length of second stage of labour among women with a vaginal birth, by parity





The duration in minutes between time of full dilation and time of birth among women with a vaginal birth. Rates are presented overall and among those women who used epidural for pain management during labour.

The median length of the second stage of labour was 70 minutes among nulliparous women (i.e., parity = 0) and 17 minutes among multiparous women (i.e., parity ≥1).

The median length of the second stage was longer among women who used an epidural for pain management during labour in both nulliparous and multiparous women.


Fetal Mortality Stillbirth, defined as the death of a fetus >20 weeks of gestation or >500 grams, accounts for a large proportion of perinatal deaths (deaths that occur between 20 weeks of gestation and the end of the first week after birth).49 Stillbirth can result from a range of pathophysiologic circumstances that include congenital anomalies, infection, placental abruption, and fetal malnutrition;49 however, a large proportion of stillbirths have an unknown cause of death.50 Risk factors for stillbirth include advanced maternal age, maternal smoking, high pre‐pregnancy maternal body mass index, multiple gestation pregnancies and low socioeconomic status.49,50 Comparisons of stillbirth rates across geographical locations or over time are complicated by variations in stillbirth registration practices.51 This especially affects stillbirths at very low birth weights and gestational ages51 and for this reason, calculating gestational age or birth weight‐specific rates of stillbirth improves comparability of rates.51,52 According to the Canadian Perinatal Health Report, in 2004, the stillbirth rates >500 grams in Canada (excluding Ontario) and in Ontario were 4.3 and 3.9 per 1,000, respectively.53

Figure 4.27 Fetal mortality rate ≥500 grams, by LHIN of birth Greater Toronto Area (GTA) LHIN Region, 2009–2010




The number of stillbirths ≥500 grams (g), per 1,000 total births ≥500 g (live births and stillbirths) (in a given place and time).

Across the GTA, the rate of stillbirth ≥500 g was 3.88 per 1,000 total births.

There was variability in the rates of stillbirth ≥500 g by LHIN of birth. Stillbirths may be more likely to occur in hospital sites with a higher level of care designation because these hospitals provide care to a higher frequency of women with high‐risk pregnancies. LHINs with a higher number of hospital sites providing Level III care may thus have higher rates.


Preterm Birth Preterm birth, defined as the proportion of live births with a gestational age <37 completed weeks,54 is a common, very serious and costly problem.55 In Canada (excluding Ontario), the preterm birth rate steadily increased between 1995 and 2004 to 8.2 per 100 live births.54 In the United States, preterm birth rates are even higher at about 12‐13%.56 According to vital statistics data, the rate of preterm birth in Ontario decreased between 1995 and 2004.57 More recent data from the BORN–Niday Perinatal Database show a stable rate of preterm birth between 2004 and 2008 at 8.3 to 8.4 per 100 live births.58 Reasons for increases in preterm birth rates have been attributed to increasing maternal age; increased use of assisted reproductive technology leading to more twin and higher‐order multiple gestation pregnancies; and increased prevalence of risk factors for systemic inflammation starting a cascade effect leading to cervical changes and labour.56 About 30‐35% of preterm births are medically indicated, 40‐45% follow spontaneous onset of preterm labour, and 25‐30% follow preterm prelabour rupture of membranes (PPROM).56 The majority of preterm births (60‐70%) take place between 34 and 36 weeks – commonly referred to as late preterm birth. About 20% occur at 32 to 33 weeks, 15% occur at 28 to 31 weeks, and the smallest percentage (5%) occur at less than 28 weeks.56 Babies who are born preterm are more likely to die or experience health problems during the first year after birth. In addition to the immediate costs associated with intensive hospital care that is required at birth, preterm birth creates costs related to long‐term complications such as respiratory problems, motor and sensory impairment, and neurocognitive impairment.59


Figure 4.28 Rate of preterm birth, by LHIN of birth Greater Toronto Area (GTA) LHIN Region, 2009–2010




The number of live births with a gestational age of <37 completed weeks of gestation, expressed as a percentage of the total number of live births (in a given place and time).

The rate of preterm birth (<37 weeks) across the GTA LHIN Region in 2009–2010 was 8.1%. Across Ontario, the rate was 8.2%. The majority of preterm births were between 34 and 36 weeks of gestational age at birth.

There was variability in the rate of preterm birth across the GTA LHIN Region (from 6.4% in Mississauga Halton to 11.3% in Toronto Central). Preterm births are more likely to occur in hospital sites with a higher level of care designation because these hospitals provide care to a higher frequency of women with high‐risk pregnancies. LHINs with a higher number of hospital sites providing Level III care may thus have higher rates.


Figure 4.29 Rate of preterm birth, by fiscal year Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010





The rate of preterm birth showed little change in the GTA LHIN Region between 2005–2006 and

2009–2010. In 2009–2010, the rate of preterm birth was 8.1% (95% CI: 7.9–8.3). The corresponding number of babies born at <37 weeks of gestational age was 5,854.


Figure 4.30 Rate of preterm birth, by hospital level of care Greater Toronto Area (GTA) LHIN Region, 2009–2010





The rate of preterm birth increased with increasing hospital level of care. This is expected since Level III centres provide care to a higher frequency of women with high‐risk pregnancies.


Figure 4.31 Rate of preterm birth, by plurality and fiscal year






The rate of preterm birth is approximately 9 times higher among infants born following multi‐fetal

pregnancies compared with their singleton counterparts.

The rate of preterm birth among singletons remained very stable between 2005–2006 and 2009–2010. Among twins and triplets or higher‐order multiples (≥twin), the rate of preterm birth rose very slightly from 54.3% (95% CI: 52.2–56.3) in 2005–2006 to 55.9% (95% CI: 54.0–57.7) in 2009–2010.


Fetal Growth – Small for Gestational Age and Large for Gestational Age

An infant’s size at the time of birth is universally used to assess neonatal health, both in individuals and in populations.60 Size at birth reflects both the duration of the pregnancy as well as the complex relationship between genetic predisposition and the maternal, fetal, placental and external factors that can restrict or promote fetal growth.61 To account for all of these factors when assessing an infant’s size, birth weight for gestational age is used to classify newborn infants as having normal, subnormal (small for gestational age – SGA) or supranormal (large for gestational age – LGA) size at birth in relation to some reference standard.60,62 Although there are clinical and philosophical distinctions between the two, an infant’s size at the time of birth relative to a reference standard is frequently considered reflective of the pattern of fetal growth while in utero. For instance, SGA (live born, singleton infants with a birth weight less than the sex‐specific 10th percentile for gestational age63) and the terms “fetal growth restriction” and “intrauterine growth restriction” are often used interchangeably, even though they can be completely mutually exclusive.64 SGA has been associated with an increased risk for morbidity and mortality in the perinatal period, childhood, adolescence and even later in life.64 There is a growing recognition of the relationship between SGA and adult‐onset diseases, especially metabolic‐related problems such as diabetes and obesity.64,65 Despite the use of an equitable percentile threshold on either end of the birth weight for gestational age distribution, SGA tends to receive more attention than LGA (live born, singleton infants with a birth weight greater than the sex‐specific 90th percentile for gestational age66), likely reflecting the fact that bigger babies have comparatively lower risks of mortality and morbidity.60 “Macrosomia” (birth weight above 4,000 grams or above 4,500 grams, regardless of gestational age) is a term sometimes used synonymously with LGA. Excessive fetal growth resulting in LGA or macrosomia is associated with adverse perinatal outcomes such as episiotomy, operative vaginal delivery, cesarean delivery, shoulder dystocia, and infant fracture and brachial plexus injuries.67,68 In Canada, the small‐for‐gestational‐age rate decreased between 1995 and 2004 from 10.1 to 7.8 per 100 singleton live births.63 Over the same period of time, the rate of large for gestational age increased from 9.8 per 100 singleton live births in 1995 to a high of 12.0 in 2000 and then decreased slightly to 11.6 in 2004.66 Small‐ and large‐for‐gestational‐age rates in this report are based on a Canadian, population‐based reference standard.62


Figure 4.32 Rate of small for gestational age (SGA), by LHIN of birth Greater Toronto Area (GTA) LHIN Region, 2009–2010




The number of singleton live births with a birth weight below the 10th percentile of the sex‐specific birth

weight distribution for gestational age62 expressed as a percentage of the total number of singleton live births (in a given place and time). For this report, the rate of small for gestational age is also presented using the 3

rd percentile cut‐off.

The rate of SGA (based on the 10th percentile) infants born in 2009–2010 in the GTA LHIN Region was

10.5%, slightly higher than the rate for Ontario (9.0%).

The rate of SGA (based on the 10th percentile) was approximately 10% for LHINs 6 to 9, and was 12.2% in Central West.


Figure 4.33 Rate of large for gestational age (LGA), by LHIN of birth





The number of singleton live births with a birth weight above the 90th percentile of the sex‐specific birth

weight distribution for gestational age,62 expressed as a percentage of the total number of singleton

live births (in a given place and time). For this report, the rate of large for gestational age is also presented using the 97th percentile cut‐off.

The rate of LGA (based on the 90th percentile) infants born in 2009–2010 in the GTA LHIN Region was

8.7%, slightly lower than the rate for Ontario (10.4%).

The rate of LGA (based on the 90th percentile) went from a low of 7.4% in Central West to a high of 9.8% in Central East.


Figure 4.34 Rate of small for gestational age (SGA) and large for gestational age (LGA), by fiscal

year Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010




The number of singleton live births with a birth weight below the 10th percentile (SGA) or above the 90th

percentile (LGA) of the sex‐specific birth weight distribution for gestational age,62 expressed as a

percentage of the total number of singleton live births (in a given place and time).

The rates of SGA and LGA both remained quite stable in the GTA LHIN Region between 2005–2006

and 2009–2010.


Multiple Birth Multifetal pregnancies are accompanied by increased risks for problems in both the mother and the fetuses/infants. For instance, women pregnant with multiples have more obstetrical complications such as anemia, pre‐eclampsia, preterm labour and cesarean delivery; while the fetuses/infants are at higher risk of having low birth weight, poor fetal growth, preterm birth, perinatal death,69,70 cerebral palsy and other neurodevelopmental disabilities.71 The multiple birth rate in Canada (excluding Ontario) increased steadily between 1995 and 2004, from 2.2% to 3.0%.72 In Ontario, the rates have similarly increased from 2.4% to 3.2%.57 This ongoing trend is related to increased use of assisted reproductive technology to treat infertility as well as increases in maternal age.73,74 Techniques that limit the number of fetuses in multiple gestation pregnancies (through limitations on the number of embryos transferred during assisted reproductive technology or multifetal pregnancy reduction) may lead to improved outcomes.75,76 The rising number of multiple births has financial consequences to families and society. These costs include provision of additional antenatal and intrapartum care, health care and other services to preterm babies born from a multiple pregnancy, and lifetime medical costs related to the consequences of prematurity.77,78


Figure 4.35 Rate of multiple birth, by fiscal year





The number of live births and stillbirths following a multiple gestation pregnancy, expressed as a percentage of the total number of live births and stillbirths (in a given place and time).

The multiple birth rate in the GTA LHIN Region in 2009–2010 was 3.7% (95% CI: 3.6–3.9). There has

been a very slight increase in the rate between 2005–2006 and 2009–2010 (relative increase of 9%).

The corresponding number of babies born in the region following a multiple gestation pregnancy increased from 2,352 in 2005–2006 to 2,739 in 2009–2010.


Figure 4.36 Rate of multiple birth, by LHIN of birth Greater Toronto Area (GTA) LHIN Region, 2009–2010




The number of live births and stillbirths following a multiple gestation pregnancy, expressed as a percentage of the total number of live births and stillbirths (in a given place and time).

The multiple birth rate was similar in LHINs 5, 6, 8 and 9. In LHIN 7, Toronto Central, the rate was considerably higher. This variability may be due, in part, to the concentration of Level III hospitals providing care to women with high‐risk pregnancies or to the availability of clinics providing assisted reproductive technology services.


References

1. Ontario Perinatal Surveillance System (OPSS). The Ontario Perinatal Surveillance System Report 2008. Ottawa, Ontario: OPSS; 2008.

2. The Royal College of Midwives, The Royal College of Obstetricians and Gynaecologists, The National Birth Trust. Making normal birth a reality. Consensus statement from the Maternity Care Working Party [Internet]. 2007 [cited 01 Dec 2009]. Available from: http://www.rcog.org.uk/files/rcog‐corp/uploaded‐files/JointStatmentNormalBirth2007.pdf.

3. Society of Obstetricians and Gynaecologists of Canada. A national birthing initiative for Canada. An inclusive, integrated and comprehensive pan‐Canadian framework for sustainable family‐centered maternity and newborn care [Internet]. 2008 Jan [cited 27 Nov 2009]. Available from: http://www.sogc.org/projects/pdf/BirthingStrategyVersioncJan2008.pdf.

4. Liston R, Sawchuck D, Young D; Fetal Health Surveillance Consensus Committee, Society of Obstetricians and Gynaecologists of Canada. Fetal health surveillance: antepartum and intrapartum consensus guideline. SOGC Clinical Practice Guideline 197. J Obstet Gynaecol Can 2007;29(9 Suppl 4):S3–56.

5. Young D, Lee L, Chalmers B. Fetal heart rate monitoring. In: What Mothers Say: The Canadian Maternity Experiences Survey. Public Health Agency of Canada. Ottawa, 2009. p. 131–4.

6. Graham I, Logan J, Davies B, Nimrod C. Changing the use of electronic fetal monitoring and labor support: a case study of barriers and facilitators. Birth 2004;31(4):293–301.

7. Harrison M, Légaré F, Graham I, Fervers B. Adapting clinical practice guidelines to local context and assessing barriers to their use. CMAJ 2009;DOI:10.1503/cmaj.081232.

8. Jamtvedt G, Young J, Kristoffersen D, O'Brien M, Oxman, A. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2006; Issue 2. Art. No.: CD000259. DOI: 10.1002/14651858.CD000259.pub2

9. Cunningham F, Leveno K, Bloom S, Hauth J, Gilstrap L, Wenstrom K. Induction of Labour. In: Williams Obstetrics. 22nd ed. New York: McGraw‐Hill; 2005. p. 535–45.

10. Glantz JC. Term labor induction compared with expectant management. Obstet Gynecol 2010;115(1):70–6.

11. Hoffman M, Sciscione A. Elective induction with cervical ripening increases risk of cesarean delivery in multiparous women. Obstet Gynecol 2003;101:7S.

12. Maslow A, Sweeny A. Elective induction of labor as a risk factor for cesarean delivery among low‐risk women at term. Obstet Gynecol 2000;95(6 Part 1):917–22.

13. Vahratian A, Zhang J, Troendle JF, Sciscione AC, Hoffman MK. Labor progression and risk of cesarean delivery in electively induced nulliparas. Obstet Gynecol 2005;105(4):698–704.

14. Alfirevic Z, Kelly A, Dowswell T. Intravenous oxytocin alone for cervical ripening and induction of labour. Cochrane Database Syst Rev 2009; Issue 4. Art. No.: CD003246. DOI: 10.1002/14651858.CD003246.pub2.

15. Crane J, Leduc L, Farine D, Hodges S, Reid G, Van Aerde J; Maternal Fetal Medicine Committee, Society for Obstetricians and Gynaecologists of Canada. Induction of labour at term. SOGC Clinical Practice Guideline 107. J Obstet Gynaecol Can 2001;28(8):717–28.

16. Simpson KR. Reconsideration of the costs of convenience: quality, operational, and fiscal strategies to minimize elective labor induction. J Perinat Neonat Nursing 2010;24(1):43–52.

17. Liu SL, Liston R, Fraser W. Rate of labour induction. In: Canadian Perinatal Health Report, 2008 Edition. Public Health Agency of Canada. Ottawa; 2008. p. 73–6.

18. Gülmezoglu A, Crowther C, Middleton P. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev 2006; Issue 4. Art. No.: CD004945.

19. Boulvain M, Stan C, Irion O. Membrane sweeping for induction of labour. Cochrane Database Syst Rev 2005; Issue 1. Art. No.: CD000451. DOI: 10.1002/14651858.CD000451.pub2.

20. Whitworth M, Bricker L, Neilson J, Dowswell T. Ultrasound for fetal assessment in early pregnancy. Cochrane Database Syst Rev 2010; Issue 4: Art. No.: CD007058. DOI: 10.1002/14651858.CD007058.pub2.

21. Delaney M, Roggensack A; Clinical Practice Obstetrics Committee, Society for Obstetricians and Gynaecologists of Canada. Guidelines for the Management of Pregnancy at 41+0 to 42+0 Weeks. SOGC Clinical Practice Guideline No. 214. J Obstet Gynaecol Can 2008;30(9):800–10.


22. Cargill YM, MacKinnon CJ; Clinical Practice Obstetrics Committee, Society for Obstetricians and Gynaecologists of Canada. Guidelines for operative vaginal birth. SOGC Clinical Practice Guideline No. 148. J Obstet Gynaecol Can 2004;26(8):747–53.

23. Liu S, Young D, Liston R. Rate of operative vaginal delivery. In: Canadian Perinatal Health Report, 2008 Edition. Public Health Agency of Canada. Ottawa, 2008. p. 82–5.

24. Liu S, Liston R, Lee L. Rate of cesarean delivery. In: Canadian Perinatal Health Report, 2008 Edition. Public Health Agency of Canada. Ottawa, 2008. p. 77–81.

25. Joseph KS, Young DC, Dodds L, O’Connell CM, Allen VM, Chandra S. Changes in maternal characteristics and obstetric practice and recent increases in primary cesarean delivery. Obstet Gynecol 2003;102(4):791–800.

26. National Institutes of Health. NIH State of the Science Conference Statement on caesarean delivery on maternal request. Bethesda, MD: NIH; 2006.

27. Dahlgren L. Cesarean birth by request. Cesarean Birth in BC: Trends, Perspectives & Future Strategies Consensus Conference [Internet]. 2008 [cited 27 Nov 2009]. Available from: http://www.cmnh.ca/cesarean presentations/M ‐ Dahlgren ‐ BC Consensus conference Jan 08.pdf.

28. Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS, for the Maternal Health Study Group of the Canadian Perinatal Surveillance System. Maternal mortality and severe morbidity associated with low‐risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ 2007;176(4):455–60.

29. Liu S, Heaman S, Joseph KS, et al., for the Maternal Health Study Group of the Canadian Perinatal Surveillance System. Risk of maternal postpartum readmission associated with mode of delivery. Obstet Gynecol 2005;105:836–42.

30. Robson MS. Can we reduce the caesarean section rate? Best Pract Res Clin Obstet Gynaecol 2001;15(1):179–94.

31. Betrán AP, Gulmezoglu AM, Robson M, et al. WHO global survey on maternal and perinatal health in Latin America: classifying cesarean sections. Reprod Health 2009;6:18.

32. Brennan DJ, Robson MS, Murphy M, O’Herlihy C. Comparative analysis of international cesarean delivery rates using 10‐group classification identified significant variation in spontaneous labour. Am J Obstet Gynecol 2009;201:308.e1–8.

33. American College of Obstetricians and Gynecologists. Vaginal birth after previous cesarean delivery. Practice Bulletin No. 115. Obstet Gynecol 2010;116:450–63.

34. Martel, MJ, MacKinnon CJ; Clinical Practice Obstetrics Committee, Society for Obstetricians and Gynaecologists of Canada. Guidelines for vaginal birth after previous caesarean birth. SOGC Clinical Practice Guideline 155. J Obstet Gynaecol Can 2005;27(2):164–74.

35. Tita AT, Landon MB, Spong CY, et al., for the Eunice Kennedy Shriver NICHD Maternal‐Fetal Medicine Units Network. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med 2009;360(2):111–20.

36. Farchi S, Di Lallo D, Polo A, France F, Lucchini R, De Curtis M. Timing of repeat elective caesarean delivery and neonatal respiratory outcomes. Arch Dis Child Fetal Neonatal Ed 2010;95:F78. doi:10.1136/adc.2009.168112.

37. Khangura S, Grimshaw J, Moher D. What is known about the timing of elective repeat cesarean section? Ottawa Hospital Research Institute; May 2010.

38. Canadian Institute for Health Information. 2009–2010 Childbirth Quick Stats [Internet]. 2010 [cited 14 Jun 2010]. Available from: http://www.cihi.ca/cihiweb/en/downloads/Childbirth_QuickStats_20062007_20082009_EN.pdf.

39. Canadian Institute for Health Information. Giving birth in Canada today: epidural: the popular choice. In: Giving birth in Canada: a regional profile [Internet]. 2004 [cited 14 Jun 2010]. Available from: http://secure.cihi.ca/cihiweb/products/GBC2004_regional_e.pdf.

40. O'Brien B, Young D, Chalmers B. Pain management. In: What Mothers Say: The Canadian Maternity Experiences Survey. Public Health Agency of Canada. Ottawa; 2009. p. 145–51.

41. Lieberman E, O'Donoghue C. Unintended effects of epidural analgesia during labor: a systematic review. Am J Obstet Gynecol 2002;186(5 Suppl Nature):S31–68.

42. Liu EHC, Sia ATH. Rates of caesarean section and instrumental vaginal delivery in nulliparous women after low concentration epidural infusions or opioid analgesia: systematic review. BMJ 2004;328(7453):1410.

43. Leighton BL, Halpern SH. The effects of epidural analgesia on labor, maternal, and neonatal outcomes: a systematic review. Am J Obstet Gynecol 2002;186(5 Suppl Nature):S69–77.


44. Lieberman E, Davidson K, Lee‐Parritz A, Shearer E. Changes in fetal position during labor and their association with epidural analgesia. Obstet Gynecol 2005;105(5 Pt 1):974–82.

45. Weiniger CF, Ginosar Y. Changes in fetal position during labor and their association with epidural analgesia [author reply]. Obstet Gynecol 2005;106(3):642.

46. Kotaska AJ, Klein MC, Liston RM. Epidural analgesia associated with low‐dose oxytocin augmentation increases cesarean births: a critical look at the external validity of randomized trials. Am J Obstet Gynecol 2006;194(3):809–14.

47. Hodnett E, Gates S, Hofmeyr G, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2007; Issue 3. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub2.

48. Adams ED, Bianchi AL. A practical approach to labor support. JOGNN 2008;37:106–15 DOI: 10.1111/J.1552‐6909.2007.00213.x.

49. Fretts RC. Etiology and prevention of stillbirth. Am J Obstet Gynecol 2005;193(6):1923–35.

50. Cnattingius S, Stephansson O. The epidemiology of stillbirth. Sem Perinatol 2002;26(1):25–30.

51. Joseph KS. Overview. In: Canadian Perinatal Health Report, 2008 Edition. Public Health Agency of Canada. Ottawa, 2008. p. 9–36.

52. Euro‐Peristat. Fetal mortality rate. In: European Perinatal Health Report. 2008.

53. Huang L, Allen A, Liston R. Fetal mortality rate. In: Canadian Perinatal Health Report, 2008 Edition. Public Health Agency of Canada. Ottawa, 2008. p. 136–40.

54. Liu S, Allen A, Fraser W. Preterm birth rate. In: Canadian Perinatal Health Report, 2008 Edition. Public Health Agency of Canada. Ottawa, 2008. p. 123–6.

55. Damus K. Prevention of preterm birth: a renewed national priority. Curr Opin Obstet Gynecol 2008;20:590–6.

56. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet 2008;371:75–84.

57. Public Health Agency of Canada. Canadian Perinatal Health Report, 2008 Edition. Ottawa, 2008.

58. BORN Ontario. Rate of preterm birth, 2004–2008. Unpublished data for Ontario. December 2009.

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It has been suggested that there may a “golden hour” in neonatal‐perinatal care, comparable to the concept in emergency medicine.1 Clinical assessment and care provision during the immediate hour(s) after birth can favourably impact the transition to extrauterine life, especially for preterm and/or low birth weight babies. However, even term healthy babies can be challenged by the physiological changes required to adapt from the uterine to newborn environments. Using BORN Ontario’s Niday Perinatal Database, we are able to highlight three indicators related to neonatal health and requirements for care immediately following birth. Apgar Score The Apgar score has been used as a standardized assessment of neonates for many decades. The score, which ranges from 0 to 10, represents the sum of values (0, 1, or 2) given for each of five items relating to a newborn infant’s condition – respiratory effort, heart rate, muscle tone, reflex irritability and colour.2,3 The Apgar score is measured at one and five minutes after delivery, and may be repeated at 10 minutes if the 5‐minute score remains low.4 A low score at one minute indicates that the neonate requires immediate medical attention, but it is not necessarily indicative of long‐term problems.4,5 Although 5‐minute Apgar scores of 0–3 are associated with an increased risk of neonatal death4 and cerebral palsy6 in term and preterm newborns, in isolation, scores in this range are not considered good predictors of later neurologic outcomes.6 Similarly, five‐minute Apgar scores between 4–6 have not been found to reliably predict increased risk of later neurologic dysfunction and are frequently the result of physiologic immaturity, maternal medications, the presence of congenital malformations, and other factors.5,7 The risk of poor neurologic outcomes increases when the Apgar score is 3 or less at later time points following the delivery (i.e., at 10, 15 or 20 minutes).8 Resuscitation Approximately 5–10% of newborns require some degree of resuscitation at birth, ranging from simple stimulation to assisted ventilation,9,10 and about 1% need extensive cardiopulmonary resuscitative measures to survive.11 Although the proportion of newborns requiring some form of resuscitation after birth is low, when a large birth population is examined, the corresponding number of infants is significant (e.g., 5–10% of Ontario’s annual births is approximately 7,000–14,000 babies). Respiratory Depression at Birth Respiratory depression (delay in initiating and maintaining respiration after birth) is primarily seen in infants born at preterm gestations. In term infants, respiratory depression is infrequent (5.5 per 1,000 in a recent population‐based Canadian study)12 and has been associated with a number of risk factors including intrapartum infection, placental abruption, cesarean delivery after the onset of labour and failed forceps‐assisted vaginal delivery.12 Antepartum identification of infants at risk for respiratory depression after birth may help guide important clinical decisions related to fetal surveillance, method of delivery and level of neonatal care availability at the time of birth.11,12

CHAPTER 5 POSTPARTUM AND NEWBORN


Figure 5.1 Proportion of live births with a 5‐minute Apgar score below 4 or between 4 and 6, by LHIN of birth Greater Toronto Area (GTA) LHIN Region, 2009–2010



Definition of indicator The number of infants with a 5‐minute Apgar score of 0–3 and 4–6, expressed as a percentage of the total number of live births (in a given place and time).

The proportion of neonates with a 5‐minute Apgar score between 0 and 3 was 0.3% in the GTA in

2009–2010, corresponding to a total of 227 live born infants. The majority of these 227 infants were born before 37 weeks of gestational age (70.9%).

The proportion of neonates with a 5‐minute Apgar score between 4 and 6 was 0.8%, with two‐thirds of these infants born at 37 weeks of gestational age or higher (384/575).

The proportion of neonates with a 5‐minute Apgar score less than 7 across the GTA was 1.1%, similar to the rate for the province of Ontario as a whole (1.4%).


Figure 5.2 Proportion of live births with a 5‐minute Apgar score below 4 or between 4 and 6, by hospital level of care Greater Toronto Area (GTA) LHIN Region, 2009–2010




The number of infants with a 5‐minute Apgar score of 0–3 and 4–6, expressed as a percentage of the total number of live births (in a given place and time).

As expected, the proportion of neonates with a 5‐minute Apgar score less than 7 was highest in Level III hospitals, reflecting the higher medical and obstetrical complexity of the maternal‐newborn population in these centres. In 2009–2010, 1.8% of live births (corresponding to 172 infants) in Level III centres had a 5‐minute Apgar score less than 7.

Although the proportion of infants with a 5‐minute Apgar score less than 7 was slightly higher in Level I centres (1.4%) than in Level II (1.0%) or Level II+ (0.9%) centres, the actual number of infants was smaller. In Level I centres in the GTA LHIN Region, 95 live born infants had a 5‐minute Apgar score less than 7. In Level II and Level II+ centres, the number of infants was 356 and 179, respectively.


Figure 5.3 Proportion of live births requiring resuscitation, by gestational age Greater Toronto Area (GTA) LHIN Region, 2009–2010

[Data not presented]




The number of infants who required resuscitation support with any of the following: positive pressure ventilation, chest compressions, intubation and/or drugs, expressed as a percentage of the total number of live births (in a given place and time).

In the GTA in 2009–2010, 6.7% of records in the database were missing information related to

newborn resuscitation. However, among live births at <34 weeks of gestation and those born in Level III centres, the proportion of records with missing information exceeded 30%. Since preterm infants born in higher level of care settings are more likely to require resuscitation, this indicator will not provide a reliable estimate of newborn resuscitation in the GTA and is therefore not presented.

In the current BORN Ontario reporting system, newborn resuscitation information is not being captured well at Level III hospitals due to operational practices in these tertiary centers. The higher acuity of patients at Level III hospitals necessitates more frequent utilization of resuscitation teams from the NICU. The subsequent transfer of care to the NICU team means the labour and birth staff (who usually collect this information and enter it into the Niday Perinatal Database) lose access to the resuscitation details. BORN Ontario is working with Level III hospitals to improve data capture for this data element and others.

Figure 5.4 Proportion of live births with birth depression, by gestational age


[Data not presented] Data source BORN Ontario (Niday Perinatal Database), 2009–2010



The number of infants with a 5‐minute Apgar score of 0‐3 and who required resuscitation support at birth, expressed as a percentage of the total number of live births (in a given place and time). Resuscitation support at birth was defined as a requirement for any of the following: positive pressure ventilation, chest compressions, intubation and/or drugs.

In the GTA LHIN Region, although only 6.7% of records were missing information related to newborn

resuscitation, this exceeded 30% among live births <34 weeks of gestation and those born in Level III centres. Because the definition of birth depression used here is a composite variable which requires complete information on resuscitation, this indicator will not provide a reliable estimate of birth depression in the GTA and is therefore not presented.


Breastfeeding Breastfeeding is unquestionably the best possible method of infant feeding –– it offers numerous short‐term and long‐term benefits for infants (e.g., growth, immunity and cognitive development)13–18 and mothers (e.g., reduced postpartum bleeding, delayed resumption of ovulation and improved bone remineralisation).19,20 The Public Health Agency of Canada, Health Canada, the Canadian Paediatric Society and Dietitians of Canada recommend exclusive breastfeeding (defined as breastfeeding with no other liquid or solid given to the infant21) for the first six months after birth for healthy term infants.22,23 In Canada, estimates from the Maternity Experiences Survey 2006–2007 indicate that a high proportion of women intend to breastfeed (90.0%) and initiate breastfeeding (90.3%); however, the rate of exclusive breastfeeding at six months is low (14.4%). Corresponding rates for Ontario are similar (90.4%, 90.3% and 15.6%).24 In 1989, the WHO and UNICEF launched the Baby‐Friendly Hospital Initiative (BFHI) to strengthen maternity practices that support breastfeeding.25,26 Evidence suggests that implementation of the BFHI is associated with an increase in exclusive breastfeeding duration.13,27,28 Although only three Ontario hospitals have achieved Baby‐Friendly status (Toronto East General, St Joseph’s Healthcare Hamilton and Grand River Hospital), others are actively working toward this designation. Targeted continuous quality improvement strategies are integral to achieving this goal. Certain subpopulations of women are less likely to exclusively breastfeed: women who give birth by cesarean, younger women, recent immigrants, and women with lower levels of family income.24,29 Thus quality improvement initiatives targeting one or more of these subgroups may have a substantial impact on breastfeeding rates. A recent study by Toronto Public Health found that the following BFHI policies and practices were independently associated with breastfeeding (any or exclusive), but were not widely implemented in the surveyed GTA hospitals:29

Developing a written breastfeeding policy that covers the WHO/UNICEF Ten Steps to Successful Breastfeeding

Helping mothers initiate breastfeeding within the first half hour after birth

Giving newborns no fluids other than breast milk unless medically indicated

Refraining from giving infant formula to mothers at discharge from hospital

Reviewing and discussing these policies and practices may serve as a springboard for hospitals wishing to work toward Baby‐Friendly status. Maternity health care providers are in a unique position to be able to influence and support women’s decisions regarding infant feeding and to promote exclusive breastfeeding within the care setting. The breastfeeding statistics required for Baby‐Friendly designation can be extracted from the BORN system monthly, quarterly or yearly. The database is also an excellent tool for tracking infant feeding outcomes and monitoring progress with respect to breastfeeding continuous quality improvement projects. Requests for assistance with custom breastfeeding reports can be directed to a BORN Ontario Regional Coordinator (see APPENDIX A for contact information).


Figure 5.5 Rate of exclusive breastfeeding at discharge among term live births, by LHIN of





The number of infants who were exclusively breastfed at the time of discharge from hospital, expressed as a percentage of the total number of live born infants who were >37 weeks of gestational age at birth (in a given place and time).

§ Individual hospital sites that do not collect information on breastfeeding at discharge from hospital, or that have >30% of records with missing information on this variable have been excluded from the denominator used for these calculations. This exclusion comprises 32.4% of term live births in Toronto Central and 46.8% of term live births in Central East. For the GTA LHIN Region as a whole, 17.5% of the term live births have been excluded (11,709/66,848), and for the province as a whole, 11.2% of term live births have been excluded (14,184/126,681). Notes: 1. The Breastfeeding Committee for Canada recommends calculating exclusive breastfeeding using a

denominator of live born infants >37 weeks of gestational age at birth and discharged home (i.e., not transferred to NICU or special care nursery).

30 For this report, the denominator used for calculating exclusive breastfeeding was live born infants >37 weeks of gestational age at birth. Due to data quality concerns with the discharge disposition variable in the database, we were not able to further exclude those infants who were transferred to NICU or special care nursery.

There was a large variation in exclusive breastfeeding rates across the GTA LHIN Region, from a low of

37.8% in Central West to a high of 69.3% in Toronto Central. However, note that the rates for Toronto Central and Central East should be interpreted with caution because they are based on denominators that exclude a substantial proportion of their population of term live births due to incomplete

§

§ § §


collection of breastfeeding information in some hospital sites (32.4% of term live births in Toronto Central and 46.8% of term live births in Central East have been excluded). It is unclear whether the actual rates of exclusive breastfeeding for these two LHINs are higher or lower than indicated here.

Similarly, rates of supplementation (i.e., the baby received a combination of breast milk and formula) varied by LHIN, from a low of 23.8% in Toronto Central to a high of 45.4% in Central West (data not shown in figure).

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29. Toronto Public Health. Breastfeeding in Toronto: Promoting Supportive Environments [Internet]. March 2010 [cited 25 Nov 2010]. Available from: http://www.toronto.ca/health/breastfeeding/environments_report/pdf/technical_report.pdf.

30. The Breastfeeding Committee for Canada. Calculation of exclusive breastfeeding statistics: Hospitals & birthing centres [Internet]. March 2007 [cited 1 Dec 2010]. Available from: http://www.breastfeedingcanada.ca/pdf/Exclusive%20breastfeeding%20statistics%20‐%20hospitals%20March%202007.pdf.


The principle of medical screening tests is to identify individuals who may have a disease or defect and those who probably do not have a disease or defect.1 Some screening tests are individual, while others are more predictive if done in combination. If a screening test is positive, further diagnostic testing may be done to confirm or rule out the suspected problem and to plan treatment, if necessary. Screening tests performed during pregnancy and in the newborn period are used to identify women, fetuses and babies at higher risk of having a disease or other problem. Common screening tests during pregnancy include maternal blood or urine tests to detect either maternal problems (e.g., gestational diabetes), or fetal genetic disorders (e.g., trisomy 21); ultrasound to look for fetal structural problems (e.g., gastroschisis); and vaginal swab to screen for group B streptococcus. Shortly after birth, newborns are screened for hearing loss and for genetic or metabolic problems. BORN Ontario collects data on various screening tests to monitor trends in use of tests as well as geographic differences in use. This allows us to contribute data to those making policy decisions about resource utilization.

In this report we are able to present information on:

prenatal screening that detects fetuses at potentially higher risk of certain congenital anomalies and genetic conditions

group B streptococcus screening

postpartum newborn screening to detect babies at risk for one of 28 rare diseases

postpartum screening done in hospitals to identify families and newborns at risk that may require special services (Parkyn screening – provided by the Ontario Ministry of Children and Youth Services)

The BORN Ontario Niday Perinatal Database also collects information on infant hearing screening to detect babies at risk for hearing loss. For the present report, the proportion of infants who receive hearing screening is not reported due to inconsistencies with data capture and entry for this information across all hospital sites. BORN Ontario is actively engaged with partner organizations to try and improve data capture and quality.

CHAPTER 6 MATERNAL AND NEWBORN SCREENING


The Ontario Maternal Multiple Marker Screening Program coordinates integrated prenatal screening at the provincial level in Ontario. Early in pregnancy, women should be offered and can then choose whether or not to receive prenatal screening to determine the chance of having a baby with Down syndrome, trisomy 18 or an open neural tube defect, based on ultrasound and/or biochemical assessments. Further information on this screening program is available at:

http://www.health.gov.on.ca/english/public/program/child/prenatal/.

Figure 6.1 Ratio of maternal multiple marker screening, by LHIN of residence Greater Toronto Area (GTA) LHIN Region, 2009–2010

Data source BORN Ontario (Ontario Maternal Multiple Marker Screening Program Database and Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on residence at time of screening


The number of women who had maternal multiple marker screening completed, expressed as a ratio of the total number of women who had a live birth or stillbirth (in a given place and time).

Notes: 1. The numerator information originates from the Ontario Maternal Multiple Marker Screening Program Database and the denominator from the Niday Perinatal Database. These two data sources are not linked together and have some differences in the target population for data collection. For example, women who underwent maternal multiple marker screening and had a pregnancy loss prior to 20 weeks of gestation would not be recorded in the Niday Perinatal Database.

2. Women who are screened in 2009–2010 may give birth in 2009–2010 or 2010–2011.

The ratio of women who underwent maternal serum screening during their pregnancy per 100 women who gave birth in 2009–2010 was 72.2% across the GTA, ranging from 63.5% among women who lived in Mississauga Halton to 85.7% among women who lived in Toronto Central.


Over the years, there have been various recommendations related to screening for group B streptococcus in pregnancy. Variations have included screening at different gestational ages, screening by various risk categories, and screening all pregnant women. The most current (2004) guidelines from the Society of Obstetricians and Gynaecologists of Canada recommend offering all women screening for group B streptococcal disease at 35 to 37 weeks’ gestation and treating all women who deliver prior to this gestational age unless there has been a negative culture within five weeks.2 There are also recommendations for other women who require treatment in the guidelines. BORN Ontario collects information on whether or not women within this gestational age group receive screening and antibiotics for group B streptococcus prophylaxis. This type of surveillance is useful as a quality improvement strategy and to track adherence to clinical practice guidelines. Feedback of this information to care providers may help raise awareness and compliance with guidelines.

Figure 6.2 Proportion of women who were screened for Group B Streptococcus among women who delivered at ≥37 weeks of gestation, by LHIN of birth Greater Toronto Area (GTA) LHIN Region, 2009–2010

Data source BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth


The number of women who had Group B Streptococcus screening completed, expressed as a percentage of the total number of women who delivered at ≥37 weeks of gestation (in a given place and time).


Among women who delivered at or after 37 weeks of gestation, the proportion screened for Group B

Streptococcus during pregnancy was high across all LHINs of the GTA.

*


Newborn Screening Ontario tests a small blood sample, usually taken from a baby’s heel within a defined time period after birth, to determine whether they might be at risk of having one of 28 rare but treatable diseases. A thorough description of the screening program, including the conditions that are included in the screening panel, is available at: http://www.newbornscreening.on.ca.

Figure 6.3 Number of infants with newborn screening completed and proportion who screen positive, by LHIN of residence Greater Toronto Area (GTA) LHIN Region, 2009–2010

LHIN of residence

Number of infants with newborn screening completed

Number with a positive screen

Proportion of infants with a

positive screen

LHIN 5 – Central West 10,900 94 0.86

LHIN 6 – Mississauga Halton 12,036 94 0.78

LHIN 7 – Toronto Central 12,695 115 0.91

LHIN 8 – Central 18,331 166 0.91

LHIN 9 – Central East 15,722 144 0.92

GTA LHIN REGION 69,684 613 0.88

ONTARIO 142,990 1,312 0.92

Data source

BORN Ontario (Newborn Screening Ontario Database), 2009–2010 Local Health Integration Network (LHIN) based on residence at time of screening


The number of infants with a positive newborn screening test, expressed as a percentage of the total number of infants with newborn screening completed (in a given place and time).

Notes: 1. The Ontario total includes 6,256 records that could not be mapped to a LHIN of residence (either due to missing or invalid postal code information). It is possible that some of these records were for infants from another province.

2. Screening records for infants who resided outside Ontario were excluded from the total.

The proportion of infants in the GTA LHIN Region with a positive screen on newborn screening was 0.88% of all those with screening completed.

Note that a screen positive result does not mean that the baby has a particular disease; however, it does mean that the baby has an increased risk of having a disease and requires additional follow‐up.


The Parkyn Tool is used to screen newborns for risk of developmental disabilities because of birth complications/outcomes, social issues or health issues in the newborn’s environment. The screening tool is completed by nurses prior to hospital discharge and then forwarded to the public health unit. Higher scores (nine or greater) are used to help public health nurses target families who may require early assessment and assistance.

Figure 6.4 Ratio of Parkyn screen completion, by LHIN of residence Greater Toronto Area (GTA) LHIN Region, 2009–2010

Data source Integrated Services for Children Information System (ISCIS), Ontario Ministry of Children and Youth

Services and BORN Ontario–Niday Perinatal Database, 2009–2010 Local Health Integration Network (LHIN) based on residence at time of screening


The number of infants who had a Parkyn screen completed, expressed as a ratio of the total number of live births (in a given place and time).

Notes: 1. The numerator information originates from the Integrated Services for Children Information System (ISCIS) database and the denominator from the Niday Perinatal Database. These two data sources are not linked together and may have some differences in the target population for data collection.

The ratio of Parkyn screen completion per 100 live births in 2009–2010 was 83.0% across the GTA, with little variability across the LHINs.


Figure 6.5 Proportion of infants who received a Parkyn screen score of nine or greater, by LHIN of residence Greater Toronto Area (GTA) LHIN Region, 2009–2010

Data source Integrated Services for Children Information System (ISCIS), Ontario Ministry of Children and Youth

Services 2009–2010 Local Health Integration Network (LHIN) based on residence at time of screening


The number of infants who received a Parkyn screen score of nine or greater (indicating high risk), expressed as a percentage of the total number of infants with a completed Parkyn screen (in a given place and time).

In 2009–2010 in the GTA, the proportion of infants who were screened using the Parkyn Tool and received a score of nine or greater (indicating high risk) was 18.7% (11,104/59,471). This varied from a low of 15.2% of infants in Central LHIN to a high of 22.9% in Central West LHIN. The overall proportion of infants in Ontario who were screened and received a Parkyn screen score of nine or greater in 2009–2010 was 20.7%.


References

1. Porta M, Ed. A dictionary of epidemiology, 5th edn. New York: Oxford University Press, 2008.

2. Money DM, Dobson S; Canadian Paediatric Society, Infectious Diseases Committee, Society of Obstetricians and Gynaecologists of Canada. The prevention and early onset of neonatal group B streptococcal disease. SOGC Clinical Practice Guideline 149. J Obstet Gynaecol Can 2004;26(9):826–32.


APPENDIX A

BORN Ontario Contact Information

BORN Ontario Scientific Office

Mark Walker, Scientific Director Tel: (613) 737‐8899 ext 76655 Email: [email protected]

Ann Sprague, Scientific Manager Tel: (613) 737‐8579 Email: [email protected]

Deshayne Fell, Epidemiologist Tel: (613) 737‐8899 ext 73933 Email: [email protected]

BORN Ontario Coordinators

Barbara Chapman, Quality Management Specialist Tel: (905) 580‐1637 Email: [email protected]

Erie St. Clair and South West LHINs Monica Poole Tel: (226) 268‐2819 Email: [email protected]

Waterloo Wellington and Hamilton, Niagara, Haldimand, Brant LHINs Kelly Pearce Tel: (905) 521‐2100 ext 73827 Email: [email protected]

Greater Toronto Area Vivian Holmberg Tel: (416) 305‐7726 Email: [email protected] Tammy Budhwa Tel: (289) 218‐8248 Email: [email protected] Connie Bartley Tel: (416) 586‐4800 ext 7449 Email: [email protected]

South East and Champlain LHINs Cathy Ottenenhof Tel: (613) 549‐6666 ext 4622 Email: [email protected]

North Simcoe Muskoka, North East and North West LHINs Glenda Hicks Tel: (705) 523‐7100 ext 3320 Email: [email protected]


APPENDIX B

Accessing BORN Ontario Data

We assist individuals and groups with acquiring and using BORN Ontario data for quality improvement or research projects. BORN Ontario generally receives three different types of requests for assistance with data:

1. Assistance with accessing and using BORN data collected within the person’s own institution. These types of requests are usually handled by the BORN Regional Coordinators (contact information in APPENDIX A).

2. Requests for aggregate information about certain variables, such as the rate of cesarean delivery within a certain region (e.g., LHIN or the entire province). In this case, the request is received and evaluated by BORN Ontario. If there are no privacy issues or concerns about how the data will be used, and the data are truly aggregate, BORN logs the request and provides the data once appropriate agreements are signed regarding security and publication. A data request form for aggregate data can be found on the website: www.bornontario.ca.

3. Requests for a dataset with some variables that may be considered personally identifying information. This type of request is usually associated with a particular research question or quality improvement initiative for which the individual wants to have the freedom to analyze the data to draw conclusions or test a hypothesis. BORN manages this type of request in accordance with the provisions of the Personal Health Information Protection Act (PHIPA).

For applications relating to Personal Health Information, BORN Ontario adheres to the principle of providing the minimum personal health information necessary for the purposes of the research. BORN works with the Electronic Health Information Laboratory (eHIL) at the Children’s Hospital of Eastern Ontario (CHEO) to de‐identify data sets. We are also currently working with the Research Ethics Board (REB) at CHEO to assess all BORN data requests and doing expedited REB review as warranted. Before contacting BORN Ontario with requests for data, we encourage researchers to learn more about the data we have available. A comprehensive list of variables is available on our website (http://www.bornontario.ca/data/data‐requests). For other BORN Ontario founding partner data, please contact us and we will guide you to information on their data variables. Please contact Ann Sprague ([email protected]) for data application requests, including further breakdown of the data tables provided in this report.


APPENDIX C

Number of total hospital births, by hospital site and fiscal year Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010

Fiscal Year

2005–06 2006–07 2007–08 2008–09 2009–10 LHIN Hospital

n n n n n

Headwaters Health Care Centre § 120 722 789 721

William Osler Health Centre ‐ Brampton Civic Hospital

4,182 4,360 4,657 4,558 4,754 Central West

William Osler Health Centre ‐ Etobicoke General Hospital

2,789 2,826 2,677 2,602 2,566

Halton Healthcare Services ‐ Oakville

2,210 2,286 2,124 2,407 2,300

Halton Healthcare Services ‐ Georgetown

244 311 333 434 403

Halton Healthcare Services ‐ Milton

702 876 964 971 1,021

Trillium Health Centre ‐ Mississauga

4,221 4,419 4,397 4,247 4,171

Mississauga Halton

Credit Valley Hospital 4,944 4,859 4,945 4,924 4,950

Mount Sinai Hospital 6,891 6,533 6,799 6,727 6,745

St. Michael's Hospital 2,471 2,753 2,642 2,981 2,991

Sunnybrook Health Sciences Centre

3,399 3,752 3,698 3,650 3,564

St. Joseph's Health Centre Toronto

3,332 3,331 3,251 3,331 3,126

Toronto Central

Toronto East General Hospital 3,272 3,478 3,571 3,441 3,445

Stevenson Memorial Hospital § § § 223 288

Southlake Regional Health Centre 2,287 2,495 2,581 2,484 2,477

York Central Hospital 1,991 2,133 2,336 2,423 2,795

Markham Stouffville Hospital 2,740 2,897 2,799 3,001 3,180

Humber River Regional Hospital ‐ Church Street Site

1,974 1,988 1,926 1,903 1,723

Humber River Regional Hospital ‐ Finch Avenue Site

2,801 2,550 2,558 2,395 2,231

Central

North York General Hospital 5,559 5,736 5,710 5,705 5,759


Fiscal Year

2005–06 2006–07 2007–08 2008–09 2009–10 LHIN Hospital

n n n n n Rouge Valley Health System ‐ Ajax and Pickering Site

1,523 1,583 1,644 1,583 1,482

Lakeridge Health Corporation ‐ Oshawa

2,223 2,201 2,349 2,314 2,326

Lakeridge Health Corporation ‐ Port Perry

281 294 331 315 302

Haliburton Highlands Health Services ‐ Haliburton Facility

§ § § 6 <6

Northumberland Hills Hospital 521 474 539 600 594

Peterborough Regional Health Centre

1,304 1,389 1,395 1,488 1,476

Ross Memorial Hospital 398 397 468 398 384

Rouge Valley Health System ‐ Centenary Site

1,925 2,021 2,182 2,042 2,345

The Scarborough Hospital ‐ Scarborough General Campus

3,197 3,040 2,946 2,823 2,763

Central East

The Scarborough Hospital ‐ Grace Campus

2,507 2,514 2,697 2,490 2,285


Definition of indicator The number of total births (live births and stillbirths) to Ontario women in a hospital in one of the five LHINs in the Greater Toronto Area (GTA) in 2005–2006 to 2009–2010.

§ Not contributing to BORN Niday Perinatal Database in this fiscal year.

Notes: 1. Between 2005–2006 and 2009–2010, the BORN Ontario Niday Perinatal Database was expanding its data collection activities to include births from all hospital sites in the province with a maternal‐newborn program. Thus, a large increase in the number of births for any particular hospital site may be attributed to the adoption of the Niday Perinatal Database at that point in time rather than a true reflection of growth of the birth population. The number of births for 2009–2010 is likely to reflect the most complete estimate of the number of births for any particular hospital site since data capture was more complete than in the earlier years.


APPENDIX D

Maternal pre‐existing health condition categories in BORN–Niday Perinatal Database*

Field Name

Data Entry Options

Instructions / Definitions

Maternal pre‐existing health conditions

Pick‐list – Select one or more (default):

None

Alcohol dependence syndrome (alcoholism)

Asthma

Chronic hypertension

Diabetes insulin dependant

Diabetes non‐insulin dependant

Drug and medication use

Heart disease

Hepatitis B

HIV

Lupus

Psychiatric disorders

Thyroid disease

Other

Instructions: Indicate the maternal health conditions that pre‐existed this pregnancy. Definitions:

Chronic hypertension – hypertension that predates the pregnancy (before the 20th week of gestation)

Diabetes insulin dependent ‐ Type 1

Diabetes non‐insulin dependent ‐ Type 2

Heart disease – any pre‐existing cardiac disease (including dysrhythmias, congenital anomalies etc)

Thyroid disease – hypothyroidism, hyperthyroidism

* Note – this list has been revised for the build of the new BORN maternal child database that will be implemented in the fall of 2011.


APPENDIX E

Obstetrical complication categories in BORN–Niday Perinatal Database*

Field Name

Data Entry Options


Obstetrical complications


None

Eclampsia

Gestational diabetes

Hypertension (gestational, transient)

IUGR/SGA

LGA

Periodontal infection

Placenta previa

Placental abruption

Pre‐eclampsia

Preterm rupture of membranes (PROM)

Preterm prelabour rupture of membranes (PPROM)

Preterm labour

UTI

Other cervical/vaginal infection

Other

Instructions: Indicate all obstetrical complications during this pregnancy. Definitions:

Gestational diabetes – carbohydrate intolerance of varying severity with onset of first recognition during present pregnancy (glucose tolerance test)

Hypertension (gestational) – No proteinuria. Rise in systolic pressure of at least 30 mmHg, rise in diastolic pressure of at least 15 mmHg or a diastolic pressure of at least 90 mmHg. A BP of 140/90 on at least 2 occasions at least 6 hours apart. Mean arterial pressure of 105.

IUGR/SGA – fetus/baby below 10 percentile of mean weight for gestation

LGA – fetus/baby above the 90 percentile of mean weight for gestation

Placental abruption – premature separation of a normally implanted placenta that results in retroplacental bleeding after the 20th week of gestation and before the fetus is delivered

Placenta previa – implantation of the placenta low in the uterus either overlying or reaching the vicinity of the cervical os

Pre‐eclampsia – the development of hypertension with proteinuria, occurring after the 20th week of gestation (hypertension ‐ see above; proteinuria in a concentration greater than 3g on 24 hr urine collection)

Preterm labour – initiation of labour when fetus <37 weeks gestation and >20 weeks


Field Name

Data Entry Options


Prelabour rupture of membranes (PROM) – rupture of membranes prior to onset of labour (diagnosed with nitrazine paper or ferning)

Preterm prelabour rupture of membranes (PPROM) – rupture of membranes prior to onset of labour and fetus <37 weeks gestation and >20 weeks

UTI – urinary tract infection as evidenced by bacteria in the urine (may be asymptomatic or not)



APPENDIX F

Hospital sites and level of care Greater Toronto Area (GTA) LHIN Region

LHIN Hospital Level of Care

Headwaters Health Care Centre I

William Osler Health Centre ‐ Brampton Civic Hospital II+ Central West

William Osler Health Centre ‐ Etobicoke General Hospital II

Halton Healthcare Services ‐ Oakville II

Halton Healthcare Services ‐ Georgetown I

Halton Healthcare Services ‐ Milton I

Trillium Health Centre ‐ Mississauga II

Mississauga Halton

Credit Valley Hospital II+

Mount Sinai Hospital III

St. Michael's Hospital II

Sunnybrook Health Sciences Centre III

St. Joseph's Health Centre Toronto II

Toronto Central

Toronto East General Hospital II

Stevenson Memorial Hospital I

Southlake Regional Health Centre II

York Central Hospital II

Markham Stouffville Hospital II

Humber River Regional Hospital ‐ Church Street Site I

Humber River Regional Hospital ‐ Finch Avenue Site II

Central

North York General Hospital II+


LHIN Hospital Level of Care

Rouge Valley Health System ‐ Ajax and Pickering Site I

Lakeridge Health Corporation ‐ Oshawa II+

Lakeridge Health Corporation ‐ Port Perry I

Haliburton Highlands Health Services ‐ Haliburton Facility I

Northumberland Hills Hospital I

Peterborough Regional Health Centre II

Ross Memorial Hospital I

Rouge Valley Health System ‐ Centenary Site II+

The Scarborough Hospital ‐ Scarborough General Campus II

Central East

The Scarborough Hospital ‐ Birchmount Campus II


APPENDIX G

Distribution of live births at each level of care, by gestational age at birth and fiscal year Greater Toronto Area (GTA) LHIN Region, 2005–2006 to 2009–2010





APPENDIX H

Intrapartum complication categories in BORN–Niday Perinatal Database*

Field Name

Data Entry Options


Intrapartum complications


None

Cord prolapse

Intrapartum bleeding

Meconium

Non progressive labour/lack of descent

Non‐reassuring fetal status

Post‐partum hemorrhage

Shoulder dystocia

Suspected chorioamnionitis

Suspected sepsis (unexplained fever)

Uterine rupture/dehiscence

Other

Instructions: Indicate any intrapartum complications during this labour and birth.


1765 Alta Vista Dr. Suite 106 Ottawa, ON K1G 3Y6 P: 613‐523‐3781 F: 613‐523‐9057 www.BORNOntario.ca [email protected]

Perinatal Health Report 2009â€“2010

Documents

Transcript of Perinatal Health Report 2009â€“2010