Public data: Supporting Midwifery Practices to Use and Share - - PowerPoint PPT Presentation

Public data: Supporting Midwifery Practices to Use and Share Outcomes

BORN Conference 2019, Ottawa Vicki Van Wagner, RM, PhD Shawna DiFilippo, SM, MA Ryerson University, Toronto Midwives Collective of Toronto

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Context

• Part of a larger project aimed at encouraging midwives to

use BORN standardized reports for QI, interprofessional dialogue and for client education

• We used data from BORN standardized reports to audit
• utcomes for a large urban midwifery practice to:
• Answer questions important to midwives and clients
• Promote public sharing of outcomes data within the midwifery

community

• Develop and share tools for understanding and sharing data from

BORN midwifery standardized reports

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The Midwives Collective of Toronto

• Large urban practice in

downtown west

• 15-18 midwives attending

400-600 births/year

• Privileges at Mount Sinai

Hospital (Level III)

• Full scope of practice
• Continuity of care
• Choice of birth place
• Active teaching practice

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Williamsonwilliamson

Impact of the Toronto Birth Centre

• Toronto Birth Centre (TBC) opened Feb

2014 adding a new choice of birth place for Toronto midwifery practices

• The MCT implemented a new booking

policy in 2015 which prioritized OOH births to allow practice growth in the context of a restricted hospital birth quota

• We wanted to understand the impact on:
• Client demographics
• Place of birth
• Rates of intervention and outcomes

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Angel Zhang ArcGIS

Background

• Four Toronto midwifery practices participated in a research

project that analyzed and compared outcomes using MOR data from MOHLTC for 2003-2007

• Publication in CJMRP: Perinatal Outcomes for Four Toronto

Practices: Exploring Best Practices for Normal Birth

• Answered important questions about impact on outcomes

for practices with different scopes of practice

• Midwives used this study to inform clients about their

practice specific outcomes

• We wanted an update for MCT: BORN allows us to compare

many outcomes with this previous study

5 CJMRP, Vol 13, Issue 2, 2014

6 Poster created for an open house during the ICM Congress 2017 (International Confederation of Midwives) became a popular part of

• ur waiting area

and website Public data and client education in action using BORN data from midwifery reports

Data source

• BORN standardized reports for 5 FYs: 2012/13 – 2016/17
• BIS > Reporting > Maternal Newborn Reports:
• Midwifery Care Profile – Birth
• Midwifery Care Profile – Demographics
• Midwifery Care Profile – Labour
• Midwifery Care Profile – Newborn Outcomes
• Midwifery Care Profile – Utilization of Services
• MCT outcomes compared with outcomes of Ontario midwifery

clients overall; sub-analysis by parity for some indicators

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2012/13 – 2016/17: MCT and ON midwifery quick facts

Total MCT clients who gave birth: 2,456 Total Ontario midwifery clients who gave birth: 101,242 Average number of MCT clients who gave birth each year: 491 Average number of ON MW clients who gave birth each year: 20,248 Total MCT OOH births: 824 Total midwife-attended out-of- hospital (OOH) births: 18,721 Average MCT OOH birth rate: 33.5% Average midwifery OOH birth rate: 18.5% 5-year overall change in MCT OOH birth: 42.8% increase 5-year overall change in ON MW OOH birth: 6.4% decrease

Photo source: Kevin Liang on unsplash.com

Demographics

Characteristic MCT All MPGs Parity Primiparous 1,224 (49.8%) 44,261 (43.7%) Multiparous 1,139 (46.6%) 56,739 (56.0%) Missing 94 (3.8%) 261 (0.3%) Age ≥35 yrs 893 (36.3%) 20,239 (20.0%) ≥40 yrs 153 (6.2%) 2,069 (2.6%) Risk profile Singleton, term, vertex, no prev uterine scar 2,051 (83.5%) 81,771 (80.8%) Other Primary language other than English* 196 (12.7%) 8,211 (8.6%) Uninsured 329 (13.1%) 7,795 (7.5%) Repeat client 808 (32.2%) 39,041 (37.6%) *Based on data collected. On average, language data was missing for ~36% of MCT clients (vs ~6% for all MPGs).

• Compared with ON MW clients
• verall, MCT clients were more

likely to be primiparous, ≥35 years, speak a primary language

• ther than English, and

uninsured.

• Client parity has shifted since

2003-2007: primips = 40%, multips = 60%, uninsured = 5.6%.

• Current demographics may be

similar to other urban practices

• Primary language other than

English likely higher than reported. Table 1.0: Client demographics, 5-year totals and averages (%)

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Demographics

74.0 76.0 78.0 80.0 82.0 84.0 86.0 88.0 2012/13 2013/14 2014/15 2015/16 2016/17 Low-risk MCT Low-risk all MPGs

Figure 1.1: Clients who fit low-risk* profile

0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0 2012/13 2013/14 2014/15 2015/16 2016/17 Uninsured MCT Uninsured all MPGs

Figure 1.0: Uninsured clients

%

• MCT clients were twice as likely to be uninsured

than ON MW clients

• There was greater percentage of uninsured clients in

2012/13 for both MCT and MW clients generally possibly related to cuts to IFHP

• The proportion of MCT clients who are considered low-

risk decreased, while remaining stable for ON MW clients overall. This decrease among MCT clients

• ccurred alongside increasing OOH birth (booking policy

prioritizing OOH birth beginning 2015, and opening of TBC in 2014) and continued strong outcomes.

%

10 *Low-risk: singleton, vertex, term, no previous uterine scar.

Feb 2014: TBC opens

0.0 10.0 20.0 30.0 40.0 50.0 60.0 2012/13 2013/14 2014/15 2015/16 2016/17 Planned total OOH birth - MCT Planned total OOH birth - all MPGs Actual total OOH birth - MCT Actual total OOH birth - all MPGs

Place of birth

Figure 2.0: OOH birth, planned vs actual

%

Location MCT All MPGs Planned Tot hosp 1,304 (53.1%) 77,710 (76.6%) Tot OOH 1,152 (46.9%) 23,530 (23.2%) Home 632 (25.7%) 19,385 (19.1%) BC 500 (20.4%) 2,917 (2.9%) Other 20 (0.8%) 1,228 (1.2%) Actual Total hosp 1,632 (66.4%) 82,521 (81.4%) Tot OOH 824 (33.6%) 18,721 (18.5%) Home 561 (22.8%) 16,531 (16.3%) BC 262 (10.7%) 1,550 (1.5%) Other 1 (0.0%) 640 (0.6%) Table 2.0: Place of birth, planned vs actual, 5-year totals and averages (%)

• More MCT clients planned/gave birth OOH than ON MW clients
• OOH births declined slightly in ON since 2003-07 22% ↓ 18.5%
• MCT OOH births remained stable between 2003-2007 and

2012/13

• MCT OOH births have increased each year since the opening of

the TBC from 28.3% in 2012/13 to 40.4% in 2016/17

11 Feb 2014: TBC opens

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 2012/13 2013/14 2014/15 2015/16 2016/17 Hospital - planned -

• verall

Hospital - actual -

• verall

Feb 2014: TBC opens

Place of birth

%

Figure 2.1: MCT hospital births, planned vs actual

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• MCT’s hospital births decreased substantially with the opening of the TBC by almost 30% for planned

hospital, and by almost 17% for actual over the 5 years.

• The most dramatic increases in OOH birth were among primips: a 42% increase in planned OOH, and a 32%

increase in actual OOH. Of interest, TBC births were more likely to be planned by primips, and the MCT policy of prioritizing OOH birth was for first-time clients only, who are more likely to be primips.

0.0 10.0 20.0 30.0 40.0 50.0 60.0 Planned OOH Actual OOH Feb 2014: TBC opens

Figure 2.2: MCT OOH births, planned vs actual

%

MCT OOH birth

Figure 2.3: MCT home births, planned vs actual Figure 2.4: MCT birth centre birth, planned vs actual

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 Home - planned Home - actual Feb 2014: TBC opens 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 Birth centre - planned Birth centre - actual Feb 2014: TBC opens % %

• Among MCT clients, planned home births were more likely to result in actual home births, whereas there

was a greater difference between those planned and actual birth centre births. This may have to do with different client characteristics of those choosing home vs. TBC births.

• In 2016/17, actual home births exceeded actual TBC births.
• It would appear that the increase in TBC births among MCT clients ‘came’ from both a decrease in hospital

and home births, although this may be leveling off for home births in the most recent analyzed.

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Place of birth: parity (MCT)

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Location MCT Planned MCT Actual Hospital 1,304 (53.1%) 1,632 (66.4%) Primip 596 (48.2%) 866 (70.1%) Multip 707 (58.0%) 765 (62.8%) OOH 1,152 (46.9%) 824 (33.6%) Primip 640 (51.8%) 370 (29.9%) Multip 512 (42.0%) 454 (18.5%) Table 2.1: MCT clients’ place of birth, planned vs actual, 5-year totals and averages (%) Location MCT Planned MCT Actual Home 632 (25.7%) 561 (22.8%) Primip 287 (23.2%) 223 (18.0%) Multip 345 (28.3%) 338 (27.7%) Birth centre 500 (20.4%) 262 (10.7%) Primip 344 (27.8%) 147 (11.9%) Multip 156 (12.8%) 115 (9.4%) Other* 20 (0.8%) 1 (0.1%) Primip 9 (0.7%) 0 (0.0%) Multip 11 (0.9%) 1 (0.1%) Table 2.1 (cont’d): MCT clients’ OOH births, planned vs actual, 5-year totals and averages (%)

*Could include clinic births or undecided.

• Of clients planning OOH births, multips were more likely

to plan home births and primips TBC births.

• The association between parity and choice of OOH birth

location helps explain why transfer rates were higher for TBC than planned home births

Interventions: CS

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Intervention MCT All MPGs CS 362 (14.7%) 16,670 (16.5%) Primip 275 (22.2%) 10,392 (23.4%) Multip 87 (8.7%) 6,254 (12.6%) Risk-adjusted CS 190 (9.3%) 7,971 (9.7%) Primip 180 (16.9%) 6,955 (18.6%) Multip 10 (1.0%) 1,016 (2.3%) Table 3.0: CS, by parity, 5-year totals and averages (%)

0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0 CS - MCT CS - all MPGs CS (risk-adj) - MCT CS (risk-adj) - all MPGs %

Figure 3.0: CS births, all and risk adjusted

• CS rates have been increasing for ON MW clients-

the rate for ON MW clients was 15.1% in 2003- 2007 and 16.5% in 2012/13-2016/17.

• MCT had lower CS rates than MW clients in ON; the spike in CS in 2014/15 associated with spike in induction
• As expected, multips had the lowest rates of CS among low-risk clients and non-risk adjusted clients
• MCT’s CS rate increased from 12.1% in 2003-2007 to 14.7% in the more recent 5-year period studied
• The increase in OOH after the TBC opened appears to have had little impact on CS rates

Interventions: assisted vaginal birth

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0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 2012/132013/142014/152015/162016/17 AVB - MCT AVB - MCT - primip AVB - MCT - multip AVB - all MPGs AVB - all MPGs - primip AVB - all MPGs - multip

Figure 3.1: AVB, by parity

%

Intervention MCT All MPGs AVB 123 (5.9%) 5,868 (6.9%) Primip 95 (9.9%) 4,672 (13.7%) Multip 28 (2.5%) 1,195 (2.4%) Table 3.1: AVB, by parity, 5-year totals and averages (%)

Note: denominator (from BORN) for this indicator is ‘women who had a vaginal birth’, whereas for some intervention indicators the denominator is ‘all women who gave birth’.

• As expected, AVB was higher among primips than multips.
• AVB rates decreased slightly for MCT clients over the 5-year period analyzed, but increased slightly for ON

MW clients overall.

• AVB was highest in 2014/15 for primips (same year as increased CS rate), by 16% over the 5-yr average.

Interventions: perineal trauma

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Intervention MCT All MPGs Perineal trauma (any) 1,417 (59.8%) 57,535 (60.3%) Primip 770 (64.8%) 28,870 (68.6%) Multip 646 (54.7%) 28,661 (53.8%) Laceration only 1,300 (54.9%) 51,402 (53.9%) Primip 675 (56.8%) 24,068 (57.1%) Multip 624 (52.9%) 27,330 (51.3%) Episiotomy (incl extensions to 3rd/4th degree) 117 (4.9%) 6,133 (6.4%) Primip 95 (8.0%) 4,802 (11.4%) Multip 22 (1.9%) 1,331 (2.5%) Table 3.2: Perineal trauma 5-yr totals and averages (%)

• Rates of perineal trauma were

comparable between MCT and ON MW and stable over the 5 year study period and the 2003-2007 study.

• Similarly, episiotomy rates were low

for both MCT and ON MWs overall and consistent with 2003-2007.

• For comparison, in 2003-2007,

episiotomy rates were 5.0% for MCT and 7.6% for ON MW clients overall.

Interventions: IOL and augmentation

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Intervention MCT All MPGs Induction* 246 (10.4%) 16,740 (18.2%) Primip 153 (12.9%) 9,279 (22.0%) Multip 93 (7.9%) 7,459 (14.0%) Augmentation** 626 (26.4%) 30,456 (31.7%) Primip 423 (35.6%) 19,931 (47.4%) Multip 203 (17.2%) 10,521 (19.8%) Table 3.3: IOL and augmentations, by parity, 5-year totals and averages (%)

• IOL and augmentation rates were consistently lower

among MCT clients than ON MW clients overall, despite MCT caring for a greater percentage of primips than the average. Intervention MCT All MPGs Oxytocin 58 (33.7%) 5.020 (34.7%) Prostaglandin 8 (4.7%) 553 (3.8%) Amniotomy 38 (22%) 2,077 (14.4%) More than

• ne method

68 (39.5%) 6,823 (47.1%) Missing data 2 (2.7%) 69 (0.5%) Table 3.4 IOL method, 5-year totals and averages (%)***

*Induction can include any of: none, amniotomy, prostaglandin,

• xytocin, sweeping membranes, unknown.

**Augmentation can include any of: none, amniotomy, prostaglandin,

• xytocin, unknown.

***Denominator was those who had induced labours, not all clients who gave birth; e.g., 33.7% of MCT clients who were induced had

• xytocin only

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0 Augmentation - MCT Augmentation - MCT - primip Augmentation - MCT - multip Augmentation - all MPGs Augmentation - all MPGs - primip Augmentation - all MPGs - multip Feb 2014: TBC opens

Interventions: IOL and augmentation

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Figure 3.3: Augmentation, by parity

%

• Whereas IOL increased steadily over the 5-year period analyzed, both for MCT and ON MW clients overall,

augmentation has decreased for ON MW clients and has remained fairly consistent for MCT clients

• The outlier year for CS rates (2014/15, predominantly among primips), was also associated with a higher

rate of induction for primips (15.1% 2014/15 vs. 12.9% for the 5-year average)

• Trends unlikely to be related to increased OOH births

0.0 5.0 10.0 15.0 20.0 25.0 30.0 2012/132013/142014/152015/162016/17 Induction - MCT Induction - MCT - primip Induction - MCT - multip Induction - all MPGs Induction - all MPGs - primip Induction - all MPGs - multip

Figure 3.2: Induction, by parity

% Feb 2014: TBC opens

Interventions: pain management in labour

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Intervention MCT All MPGs No pain mgmt in labour 973 (46.6%) 35,216 (40.6%) Neuraxial total 554 (26.5%) 25,715 (29.6%) Epidural only 515 (24.7%) 24,405 (28.1%) Combo spinal epidural 36 (1.7%) 1,134 (1.3%) Spinal only 3 (0.1%) 176 (0.2%) Other pain mgmt in labour 559 (26.8%) 25,886 (29.8%) Missing data 7 (0.3%) 317 (0.4%)

%

Figure 3.4: Epidural &/or spinal (vag births only), by parity Table 3.5: Pain management in labour – vag births only – 5-year totals and averages (%)

0.0 10.0 20.0 30.0 40.0 50.0 60.0 MCT - all MCT - primip MCT - multip All MPGs - all All MPGs - primip All MPGs - multip

• Primips were more likely to have epidural/spinal, and

rates of use have increased for MCT on ON MWS

• May be related to increased rates of induction

Client transfers of care

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0.0 10.0 20.0 30.0 40.0 2012/13 2013/14 2014/15 2015/16 2016/17 MCT All MPGs %

Figure 3.5: Clients with at ≥1 transfer of care to physician Intervention MCT All MPGs Clients with ≥1 TOC 580 (23.1%) 35,257 (39.6%) Table 3.6: Clients with at ≥1 transfer of care to physician, 5-year totals and averages (%)

• In all years analyzed, MCT had lower rates of client TOCs to a physician than ON MW clients overall. An

important factor in this difference may be MCT’s full scope practice and supportive interprofessional

• team. An interesting further analysis would be to compare cost savings with minimized TOCs, especially

for practices and skills that are within midwifery scope (but require TOC for some practices/hospitals).

Note: transfers may include a large percentage that are ultimately transferred back to midwifery care, either in the same or later BORN encounter. %TOC was calculated based

• n billable courses of care.

Newborns: preterm births

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Outcome MCT All MPGs Preterm (<37 wks) 102 (4.1%) 4,795 (4.7%) Preterm (<34 wks) 24 (1.0%) 1,070 (1.1%) Table 4.0: Preterm birth (includes live and still births), 5-year totals and averages (%)

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 Preterm (<37 wks) - MCT Preterm (<37 wks) - all MPGs Preterm (<34 wks) - MCT Preterm (<34 wks) - all MPGs %

Table 4.0: Preterm birth (<37 wks, <34 wks)

• Preterm birth remained low and comparable between MCT and ON MW clients overall. Fluctuations were

within small margins.

Newborns: Apgar <7 and NICU admits

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Table 4.1: Apgar scores of <7 at 5 min and NICU admissions – 5-year totals and averages (%)

• 5-minute Apgar scores of <7 were low among

MCT and MW clients overall

• The increase in OOH birth over the 5-year

period studied was not been associated with decreased Apgar scores or increased NICU

• admissions. This is consistent with Ontario

research place of birth and outcomes. Outcome MCT All MPGs Apgar <7 at 5 min 27 (1.1%) 1,484 (1.5%) NICU admissions (term live births) 60 (2.6%) 6,504 (6.7%)

Newborns: feeding at MW discharge

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65.0 70.0 75.0 80.0 85.0 90.0 2012/13 2013/14 2014/15 2015/16 2016/17 MCT MCT - primip MCT - multip All MPGs All MPGs - primip All MPGs - multip

Figure 4.1: Human milk feeding (term births), by parity

%

Outcome MCT All MPGs Human milk only 1,978 (84.3%) 76,702 (79.2%) Primip 972 (82.4%) 31,816 (75.7%) Multip 1,005 (86.2%) 44,870 (81.9%) Table 4.2: Human milk feeding only (term births) at discharge from MW care, 5-year totals and averages (%)

%

• Human milk feeding at 6-week discharge is

high for MCT clients and MW clients

• generally. Client demographics and the

model of care are important factors.

• Of note, a 2017 Toronto Public Health

survey found that by 2 months of age, only 34.5% of respondents reported exclusively breastfeeding (ON MW clients >2x higher).

Conclusions

• Impact of TBC and prioritizing OOH births at booking was associated with:
• A decrease in planned hospital births, by 20%, and actual hospital births, by 12%
• A decrease in home births (actual), by 6%
• Increase in OOH births has supported client access and practice growth
• Practice has grown by 30%: MCT now attends 100 to 150 more births per year

than prior to TBC; client waitlist has also decreased

• MCT can now employ up to four additional midwives despite a limited hospital

birth quota

• Practice planning has to take into account need for part of our hospital birth

quota for OOH birth transfers

• This policy may have resulted in a less self-selected population choosing TBC

and higher rates of transfer from TBC to hospital

• Other outcomes remained stable despite international evidence that OOH

can decrease interventions

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Conclusions

• Limitations: it may be too early to show a trend
• Small sample size with 500 planned and 262 actual TBC births
• A BORN-led study of the first 495 TBC admissions and a matched cohort

showed lower rates of intervention, including epidural, augmentation and CS and high rates of client and care provider satisfaction/integration: Sprague et al. J Midwifery Womens Health 2018;63:532-540 Reszel J et al. J Midwifery Womens Health 2018;63:541-549

• Low baseline rates of intervention for MCT birth
• The model of midwifery practice in Ontario
• Full scope of practice for midwives
• Hospital policies and relationships with obstetrics that support low

intervention approaches for midwifery clients

• Reasons for consultation and transfer of care are consistent regardless of

place of birth

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Next steps

• Create poster with 5-year analysis for MCT practice waiting area,

website, and client handout

• AOM webinar “Benchmarking your Midwifery Practice Group”
• Share tools with other practices
• Invite other GTA practices/TBC practices to a QI meeting to

compare data across shared indicators

• Present at Rounds to our interprofessional colleagues
• Provide feedback to government about the potential for birth

centres to support the growth of midwifery

• Provide feedback to BORN about standardized reports
• Abstract accepted for the ICM in Bali

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Thank-you Merci Miigwech

vvanwagn@ryerson.ca