BIRTH CENTRE
|
|
BIRTH CENTRE |
|
To view or print a PDF file, you need the Adobe Acrobat Reader, which you may download at no charge from the Adobe web site. (Acrobat is a trademark of Adobe Systems Incorporated.) |
|
Women’s Health Clinic is delighted to see support by the leading Manitoba political parties for a Winnipeg-based community birthing centre. We also are pleased to see funding for increased numbers of funded positions for midwives and for a southern midwifery education program. Birth Centres are an important option for women and their families who are seeking a home like atmosphere in which to give birth. In Quebec and England, birth centres are a key component of maternity care. Birth Centres offer a comfortable, low-tech environment where birth is treated as a "normal" rather than a medical process. Birth centres are known for providing friendly, individualised care in an atmosphere that is informal and unhurried, staffed with highly skilled midwives. They are designed as home-like atmospheres for healthy women who are seeking a “natural” birthing experience without surgical or pharmaceutical interventions. The Birth Centre would be a “Centre of Excellence” for maternity care and “low risk” birth and, as well as providing care, would support the training of midwives, doulas, nurses and possibly other care providers. Pre- and post-natal care, as well as breastfeeding and parenting support, would also be offered. It is time for women in Manitoba to have those advantages. The demand for midwifery services exceeds the capacity of current provincial programs. Research shows that birth centres are a safe and efficient addition to maternity services. Supporting and upgrading an education program will help ensure better care now and for the future. Our Birth Centre proposal was developed with a community-based interest group, which came together in 2004 to increase birthing options for women and to strengthen support for low risk birth and midwifery. Members have included the Manitoba Association for Childbirth and Family Education, Women’s Health Clinic, midwives, doulas, and the Prairie Women’s Health Centre of Excellence, as well as birthing women and their families. Once the election is over, we look forward to working towards making the birth centre and midwifery training a reality. For further information contact Madeline Boscoe at 947-2422 ext 122 or cell 295-2946 Download the complete South Winnipeg Maternity and Birthing Centre Program Proposal and Description (3389 kb - pdf format) Selections from
South Winnipeg Maternity and Birthing Centre
For further information contact:
A. Note to Readers The following document is drawn from a very detailed funding proposal for a birth centre in Winnipeg, Manitoba that has been submitted to the Winnipeg Regional Health Authority and Manitoba Health. Given the recent announcements of strong support for a community based community birthing centre in Winnipeg that has expressed by the leading Manitoba political parties, we thought it would be helpful to increase access to information on birthing centres in general as well as this specific project. Therefore we have posted sections of the proposal and some pictures from other birth centres. The proposal includes the results of a significant literature review and consultation process. The proposal reflects that evidence and vision of women and men who contributed to the proposal. But it is just that, a proposal. We have a journey, and many meetings ahead, before the doors are open. Birth Centres are an important option
for women and their families who are seeking a B. Introduction and Overview
For many years, Winnipeg women have been talking about the need to establish a community based Birth Centre. In 2004, a community-based interest group came together to work for increased birthing options for women and to strengthen support for low risk birth. This led to the formation of a committee to look at the feasibility of a Maternity and Birth Centre in Winnipeg. Committee members included representatives of the Manitoba Association for Childbirth and Family Education, Women’s Health Clinic, midwives working in Winnipeg and the North, community agencies, post natal and parenting educators, doulas, the Prairie Women’s Health Centre of Excellence, birthing women and their families. On behalf of this group, the Women’s Health Clinic obtained funding from the Winnipeg Foundation to develop this proposal [2]. This proposal describes a community-based and community-governed Maternity and Birth Centre, located in South Winnipeg that will provide a family-centred, primary maternity care for low-risk women and their babies[1]. As envisioned the Centre will provide prenatal and postnatal education and care, and be an out-of-hospital facility for low-risk, midwifery-attended birth. In preparing this proposal, the team undertook: · a thorough review and synthesis of the research literature; · interviews and site visits to Birth Centres in Germany, USA, England and Canada; · more than 60 interviews with maternity care providers, managers, community members and researchers. The results of these efforts are synthesized in this proposal. From this review, we have learned at Birth Centres are a safe and efficient addition to the health care services system if they operate with a carefully selected population and within an integrated collaborative maternity care program. The Goals of the proposed South Winnipeg Maternity and Birth Centre are:
This proposal is part of a history of innovation and leadership in the provision of women’s health care, builds on the existing strengths in our current system of maternity care in Manitoba and seeks to address some of the challenges we currently face. Examples of Manitoba’s innovation, leadership and strengths in the provision of care include: · Dr. Elinor Black became the Head of the Dept. of Obstetrics and Gynecology at the University of Manitoba in 1951. She was the first woman in Canada to head a University medical department. · The 1982 Community Task Force on Maternal and Child Health, which led to establishment of a Maternal and Child Health Directorate within Manitoba Health in 1986. It was disbanded in 1994. The Community Task Force Report also led by stressing the importance of socio-economic factors in maternal newborn health [54]. · Four Labour, Delivery, Recovery and Postpartum (LDRP) units were established in Winnipeg hospitals. Two of these still operate at the St. Boniface Hospital and the Health Sciences Centre, the two hospitals that continue to provide maternity care in Winnipeg. · In 2000, the Minister of Health and the Minister Responsible for the Status of Women jointly published Manitoba’s Women’s Health Strategy, giving direction and setting priorities. · Manitoba has established midwifery as a regulated profession, with midwives employed by RHAs. Midwifery services are funded by the Province and midwives are expected to focus their care on identified priority populations [5]. The MB Midwifery Discharge Summary Database 2001/06 reports that 60% of midwifery clients are from the “targeted[2]”, i.e. priority populations. Midwifery clients have lower intervention rates, and half the number of preterm, low and high birth weight babies compared with Manitoba rates as a whole. [Betsi Dolin, Manitoba Health]. This demonstrates that midwives are seeing the appropriate clients, i.e. those who are defined as medically low risk. · Manitoba’s groundbreaking KOBP Aboriginal Midwifery Education Program, based at the University College of the North, began accepting students in September 2006. · Higher rates of normal vaginal births than other provinces/territories (due to both lower rates of Caesarean sections and lower rates of assisted vaginal births) [11, 14]. · Support for maternal and newborn health outside of the traditional health care services delivery through the Healthy Child Manitoba Strategy, including the Healthy Baby, Families First and Fetal Alcohol Syndrome prevention initiatives and Manitoba’s new K- S4 Health curriculum. At the same time, we are also experiencing the same challenges as other provinces in Canada. These include: · Decreasing capacity in rural and northern regions to provide care to pregnant women and their newborns; · Decreasing human resources (physicians, particularly obstetricians and family physicians, midwives and nurses). Increasing numbers of family physicians are leaving the practice of obstetrics and we have an aging obstetrical workforce; · Increasing centralization of births in Manitoba at two tertiary hospitals in Winnipeg; · Increasing surgical and medical interventions in the childbirth process; · Health outcomes for pregnant women and their newborns in Manitoba, which are worse than that of many other Canadian provinces (including preterm birth rates, neonatal and post neonatal deaths and maternal hospital readmissions) [2, 3, 11, 13, 14]. Note: this is likely due to public health factors such as age and socio economic status, not as a result of factors related to health service delivery. · Reliance on specialist and tertiary care to provide primary care · Decreased opportunities for physicians and nurses to teach and learn the skills needed to assist women during birth, where birth is valued as a normal, physiological process. · A desire for a wider range of birthing options by pregnant women and their families. Currently in Winnipeg, all women, except for those who opt for home birth, must give birth at either the Health Sciences Centre or the St. Boniface Hospital. This proposal will build on our strengths and help
address several of these challenges.
The Birthing Centre will be a centre of excellence for primary maternity care and low risk birth.[3] As envisioned, it will provide:
The Maternity and Birth Centre will operate within Medicare as part of Manitoba’s publicly insured health care system. Like the other components of the Women’s Health Clinic, the Centre will operate under a Service Purchase Agreement with the Winnipeg Regional Health Authority (WRHA) with WRHA midwives placed there as they currently are in other primary care agencies. While this will be Manitoba’s first such facility, birth centres are well established in other jurisdictions including England and the USA. In Canada, publicly funded birth centres exist in Québec, Nunavut, and Ontario (Six Nations Reserve). Québec is currently expanding its program of birth centres from the existing seven southern and three northern facilities to 21 [9]. There is also a private birth center (the Arbour Center), which operates on a fee-for-service basis in Calgary. We believe that demand for the Maternity and Birth Centre will be high. Experience in other jurisdictions, notably Québec and England has shown that birth centres are extremely popular with pregnant women and their families. Research conducted by the Government of Québec showed that 15% of Québec women of childbearing age would prefer to give birth in a Birth Centre [8]. Indeed, all birth centres in Quebec are working past capacity and maintain a form of a ‘waiting list’. This proposal will move Manitoba along the path of
sustainable family-centred maternity care. Because the South Winnipeg
Maternity and Birth Centre will operate within the WRHA, and with the active
support of both midwives and family physicians, it can serve as an important
demonstration of these principles in action.
The challenges in maternity care in Canada are now well recognized. Fewer physicians, especially family physicians provide maternity care, especially intrapartum care to women during childbirth [13]. Fewer local hospitals provide maternity care. For rural and northern women, this means that many more must now travel long distances in order to give birth. Surgical and pharmacological interventions in the birthing process have increased, and along with this, the risks posed to birthing women and their babies. In 2001-02 only one-quarter of births in Canada occurred without surgical intervention (the use of instruments, induction, or epidural/general anaesthetic). At the same time there is concern that skills to support birth without surgical and pharmacological support are in peril of being lost [13, 14]. Quebec, Manitoba, BC and Ontario have all completed reviews of their maternity care programs recommending actions for change [3, 55]. These include: · expansion of rural maternity care services · incentives for family physicians to provide maternity care · expansion of midwifery · birth centres – planned in Ontario and BC In addition, the Government of Québec plans to increase the number of birth centres from 7 to 21, with a goal of having 10% of all births attended by midwives [9]. Here in Manitoba Each year, about 18,000 Manitoba women become pregnant. About three-quarters of these pregnancies result in a live birth. In 2002/03, there were 13,464 babies born in Manitoba. Of these, 9,130 or about 68% were born in Winnipeg hospitals. Winnipeg women giving birth are largely attended by specialist obstetricians. From 1988/89 to 2002/03, obstetricians provided care for increasing percentages of both “high risk[4]” and “low risk” women. In 1988/89 obstetricians provided intrapartum care for 82% of high-risk women and 68%of low risk women giving birth in Winnipeg. By 2002/03 this had increased to 94% of high-risk women and 87% of low risk women (personal communication, Manitoba Health and Manitoba Healthy Living staff). In contrast, in 1988/89, family physicians provided intrapartum care for 23% of high-risk women and 42% of low risk women. By 2002/03 this had decreased to 16% of high-risk women and 28% of low risk women (personal communication, Manitoba Health and Manitoba Healthy Living staff). As in other parts of Canada, fewer community hospitals provide elective maternity care. In Winnipeg, all hospital based maternity care is now provided at the two tertiary care hospitals. From 1990 to 2005, the number of hospitals outside of Winnipeg offering maternity care decreased from 22 to 17. This means that more women are required to travel far from their home communities in order to give birth. Increasingly, birthing women are attended by maternity care providers who do not know them or their families. Fewer family physicians are providing intrapartum care. Fewer family physicians providing intrapartum care means fewer to teach and mentor family practice residents. Without action, this will mean even fewer family physicians will have the skills to provide intrapartum care to rural and northern women in the future. Already, about 50% of women outside of the Winnipeg and Brandon RHAs leave their RHA for childbirth. Many more leave their local communities (personal communication, Manitoba Health and Manitoba Healthy Living staff). The introduction of regulated midwifery in Manitoba in 2000 provided an important additional service for pregnant women, one that supports the promotion of pregnancy and birth as a normal physiological process and an important spiritual and cultural event in the lives of women and their families [49, 50]. However, the number of midwives is small, with 16 working with the WRHA, 11 in rural Manitoba and 5 in Northern Manitoba. Demand for midwifery services has consistently been greater than the supply of midwives would allow. During the first nine months of 2006, WRHA midwives were able to accept into care fewer than half (44%) of all women who requested midwifery care [10]. Other RHAs with midwives experience similar demands and have identified the need to increase midwifery resources to address maternal care needs. From 2001 to 2006, midwives attended about 5% of births in Manitoba. About 62% of midwifery clients came from the identified priority populations, women who are: immigrants and refugees, or Aboriginal, or women who are single, adolescent, poor or are socially isolated or at risk for other reasons [56]. About 18% of midwifery clients (or about 1% of all women giving birth) chose to give birth at home. Manitoba midwives offer planned out-of-hospital births to clients who wish to give birth in a home-like setting, and who can safely do so. The four-year KOBP Aboriginal Midwifery Education Program at University College of the North [50], will train midwives committed to practising in northern Manitoba. However, there is currently no training program for midwives for rural and urban Manitoba. With the co-operation of the College of Midwives, mentoring midwives, the Province, the WRHA and the Women’s Health Clinic, the Maternity and Birth Centre can serve as a practicum site for midwifery students registered for self-study or the anticipated “Bridging” program that will provide upgrading and skill development for midwives trained outside of Canada and Manitoba, leading to registration as a midwife in Manitoba. In Manitoba, as in the rest of Canada, there have been increasing interventions in the childbirth process, including increased rates of birth by Caesarean section, increased use of analgesia and anaesthesia during labour and assisted vaginal births (by forceps or vacuum extraction) [3, 11, 14]. When appropriately used, such interventions are life saving for mothers and babies. However, increasing reliance on these technologies is concerning, and each carries its own associated risks. Continuity of caregiver, and continual labour support, as would be provided to all women at the Maternity and Birth Centre, is associated with significant reductions in Caesarean sections, assisted vaginal deliveries and the use of pain medications during labour [12]. Birth Centre care has been demonstrated to result in fewer medical and surgical interventions in birth [16, 36].Care at the Centre will be grounded in the belief that the least intervention possible creates the best opportunity for a good birth experience. The Centre will be a place in which births take place without the use of medical or surgical inductions of labours, Caesarean section, suction or forceps. While interventions in birth can be life saving, each carries its own attendant risks and increases costs to the system through increased lengths of stay and increased hospital readmissions [11, 13, 14, 61]. While Manitoba has lower intervention rates of intervention in birth than the Canadian average, these rates have been increasing as it has been in other parts of Canada, and in other jurisdictions In developing this proposal, we have been guided by the lessons of the research we reviewed and our site visits. These include: · a commitment to the philosophy of birth as a normal event is essential; · the facility’s design should be home like, quiet and peaceful with space for walking and easy outside access; · continuity of care and care providers preferred by clients and by most midwives. · active engagement of birthing women and their families in the management of the centre is important.
D. Birth Centres –
Experiences in Other Jurisdictions Over the last several decades, maternity care and childbirth throughout the world have increasingly been concentrated in large urban hospitals. This change in the predominant model of maternity care has been paralleled by increased rates of obstetrical interventions including an increase in Caesarean section rates and other obstetrical interventions. This has prompted policy makers, practitioners and users of the services to seek alternatives to this trend and in particular, to create options for women who are not expected to have complications in their pregnancy. The establishment of birthing centres worldwide has thus been a response to the need to provide women with extended choice in maternity care including the place of birth. It is consistent with the objectives of international reviews of maternity care and policy initiatives that support midwifery and well integrated, community based birthing options [17, 26, 27, 37, 51]. United Kingdom In the UK, the establishment of midwifery-led birth centres is a relatively new concept that has gained popularity within the National Health Service NHS in the last five years. The primary objective for the establishment of Birth Centres has been a desire to provide women with additional options for their birth and maternity care. The trend has been consistent with and in response to the objectives of national reviews of maternity care (Changing Childbirth 1993) and more recent policy initiatives (National Service Framework for Children, Young People and Maternity Care 2004 [27, 38]. In addition, the establishment of Birth Centres has been in response to efforts by women to retain local community based birthing services as the trend to centralizing births in consultant units (in tertiary care hospitals) has become more common [38]. Birth Centres are also seen as a place where midwives can function within their scope of practice and where normal birth is supported [25, 26]. While Birth Centres may be geographically separate from local consultant units (specialist services), they are fully integrated within local referral networks and emergency services. A National Birth Centre Network has been recently established that provides a framework for the development and evaluation of birth centres throughout the UK. At the present time there are approximately 50 free-standing birth centres in the UK with more planned in the near future (email message from Soo Downe to Kris Robinson, October 2006). The Royal College of Midwives has recently issued a Policy Statement supporting the establishment of birth centres as a safe, satisfying and cost effective alternative for women who are experiencing normal pregnancy and birth [15]. UK Birth Centres generally provide a location for midwifery-led prenatal and postpartum care , births with a limited postpartum stay, and prenatal and parenting education. Most have a core group of midwives on staff and provide for 250 to 500 births per year. A comprehensive evaluation of the Edgware Birth Centre in London, the first evaluation of its kind in the UK, demonstrated that the centre provided safe, cost-effective care and was associated with high levels of maternal satisfaction. Midwives at the centre also reported high levels of job satisfaction [42, 58, 59]. The Edgware Birth Centre has emerged as a model for the establishment of other free-standing centres throughout the UK [27]. United States In the United States, Birth Centres have a well-established history and 74% of US states have regulations and licensing requirements for Birth Centres. There are 175 birth centres throughout the US, 100 have formal membership in the American Association of Birth Centres. This national organization sets standards for Birth Centres and provides consultation services for the establishment Birth Centres throughout the US. Midwives provide care in the majority of birth centres, most on a fee for service model. All have well defined criteria for client selection, consultation and referral and over 50 have full accreditation with the American Association of Birth Centres [20, 24]. Elsewhere in the world the move to establish birth centres is gaining popularity as the policy makers, practitioners and women seek to establish additional choices within the context of maternity care reform. Birth centres are being seen as a viable option, which provides safe, locally accessible services for women who are anticipating a normal birth within an environment which is modeled on a home rather than a hospital setting [15, 26]. The Canadian Experience The establishment of Birth Centres in Canada is increasingly being seen as an important component of maternity care reform. Provincial reviews of maternity services have called for the establishment of new and creative options for care during pregnancy and childbirth [3, 55]. In addition, communities in northern and remote areas of the country are seeking community-based alternatives as an alternative to the long-standing policy of evacuation to southern centres for childbirth. To date Canada has limited experience with free standing Birth Centres particularly in urban areas, although there are successful examples of well-established centres in the North. In all Canadian birth centres the primary care providers are midwives and not surprisingly the establishment of birth centres has paralleled the legislation and regulation of midwifery throughout the country. The following is a brief summary of the current status of birth centres throughout the country: Northern Québec has the longest history of birth centres with the first being established in Povugnituk (Baffin Island) in 1986, Inukjuak 1998 and Salluit. These remote birth centres have provided a site for about 3,000 births during this time and have emerged as sites for the training of local women as midwives. Although the numbers are small, the outcomes from these centres have been promising given their remote locations. In Southern Québec the Québec Ministry of Health and Social Services supported the development of birth centres as pilot projects for midwifery practice in association with CLSC (Community Health Clinics) beginning in 1994. To date, seven birth centres have opened in Southern Québec. All are staffed by midwives and fully funded as part of the Québec medicare system. About 10,000 births have occurred in these birth centres. The Québec Ministry of Health and Social Services is actively pursuing the expansion of birth centres in the Province. In their recent working document Projet de Politique de périnatalité: Document de travail (version de travail 18 avril 2006), the Québec Ministry of Health and Social Services recognizes the contributions of midwifery and birth centres to maternity care in the Province. They propose to increase the number of midwives in Québec so that 7,000 women per year will receive midwifery care. Their goals are: · to have 10% of births attended by midwives within 10 years · to increase the number of birth centres to 21, from the current 7 [9]. Rankin Inlet, NWT has had a Birth Centre since 1995 for women from the communities of the Hudson Bay coast and the most recent birth centre in the North has been established in Fort Smith, NWT in 2005. [48] In Alberta the private Arbour Birth Centre has been in operation since 1994 and offers it services to about 100 women per year on a fee for service model. Ontario currently has just one birth centre in the community of the Six Nations of the Grand River. In Toronto plans are underway for a birth centre, which will be established as a centre of excellence for pregnancy and normal birth at the newly redeveloped Women’s College Hospital. In September, the Ontario Maternity Care Expert Panel released its report, Emerging Crisis, Emerging Solutions. The Panel concluded that birth centres could be a valuable option in some communities. They also recommended that that Ontario should develop incentives for the creation of Centres of Excellence for Normal Birth (both within and outside existing settings) to foster a culture of minimal interventions for low-risk births, inter-disciplinary care and an educational environment for the promotion of these principles [3]. This is consistent with the current proposal. Evaluations of Birth Centres Birth centre care, when well planned and integrated with local health services appears to have good outcomes for both mothers and their babies. Careful selection of women for delivery at birth centres, and adherence to well developed standards for consultation and transfer of care are key to the successful outcomes reported in the literature [17, 24, 37, 41, 42]. Outcomes Outcome evaluations of birth centres are challenging as there is no universal definition of birth centres and the model of care and populations served are not consistent across jurisdictions. Attempts at reviews have been hampered by these challenges [60]. The most recent structured review of free-standing birth centres was conducted in 2004. In this review, five studies met the Cochrane criteria for review and for the outcomes reported-normal vaginal births, intact perineum, caesarean section, episiotomy, non separation of mother and babies all showed a benefit for those women who gave birth at the birth centre [17]. The most comprehensive evaluation of birth centres in the United Kingdom was undertaken in the late 1980’s. The findings of this study involving over 10,000 births over a ten year period demonstrated that birth centre care provided by midwives had good outcomes for both mothers and babies and was associated with significantly lower rates of intervention than conventional hospital- based care. This study although dated, is still considered to provide sound evidence to supports the safety of birth centre care (E. Hodnett, personal communication, Oct. 2006). Other studies of birth centres also report good outcomes including lower rates of analgesia, less use of oxytocin, shorter labours and greater use of alternate positions [37, 39, 40, 43, 46]. Birth centre care is also consistently associated with high rates of maternal satisfaction [25, 39, 40] The results related to perinatal outcomes in birth centres throughout the developed world appear to show that outcomes are as good as those for women at low obstetrical risk who have their babies in hospital [17]. Transfer rates from birth centres vary among available studies with an overall range of 12-22%, with the majority occurring in the intrapartum period for non-urgent conditions. Careful selection of clients and an ongoing assessment of risk are frequently mentioned as key elements to maintain acceptable transfer rates within an overall birth centre quality assurance framework [41, 42]. In 1994, the Quebec government authorized the practice of midwifery in eight free-standing birth centres as a pilot project, prior to the legalization of midwifery. A comparative evaluation of midwifery practice in free-standing birth centres and hospital based care was undertaken after the first five years. The results indicated that midwifery care in the birth centre group was associated with less obstetrical intervention and a reduction in caesarean section rates and severe perineal injury to the mother. There were also fewer preterm births and low birth weights infants in the birth centre group but a higher stillbirth rate and a greater need for neonatal resuscitation were observed [44] Ø Both the authors of the study and others have attributed these mixed results to the fact that the evaluation took place prior to midwifery regulation, when both midwifery and birth centre practice occurred outside the established system of maternity care. As such, it was the first time a new profession, midwifery and a new model of care, birth centres were both being established, and evaluated at the same time. It was felt that this, as well as the absence of an effective system for professional collaboration and timely consultation contributed to the reported results [45]. Although a formal report of data after 2000 is not yet available, informal data gathering and monitoring has shown a greater trend to positive outcomes for both mother and baby. A further detailed report is forthcoming. (S. Harris, midwife and Suzanne Boisvin, M.Sc. inf. M.A.P, Conseillère aux programmes, Direction des services médicaux généraux et préhopitaliers personal communication, Health and Social Service, Québec, Oct. 2006). The Québec Ministry of Health and Social Services proposal to expand the number of birth centres and the number of midwives confirms their confidence in this model of care [9]. In Manitoba, we already have established systems for the transfer of care from midwives to obstetricians in case problems arise either prenatally or during labour. This includes the Standard for Consultation and Transfer of Care [Appendix Two] and consultation fees for physicians. As well, transfer procedures for out of hospital birth for emergency services and hospitals are in place. Therefore the barriers to interprofessional collaboration that existed at the time of this research in Québec do not exist in Manitoba. Cost-effectiveness As evaluations of birth centres continue, the available evidence from the UK and the US show that birth centre are no more costly than traditional models of hospital based delivery and in some cases, modest cost savings have been achieved. These savings are primarily due to the use of fewer resources (less intervention) and shorter lengths of stay [23, 25, 27]. Research is limited on the cost effectiveness of birth centres in a Canadian context but available evidence from the first five years of Quebec birth centres shows a modest cost savings from birth centre care when compared to traditional forms of prenatal care and hospital birth. Note: this information is ten years old and has not been revised to reflect 2007 costs.
Source: Ministère De La Santé et des Services sociaux. 1997. Évaluation des projets-pilotes de la pratique des sages-femmes au Québec [47] While the body of research on birth centres is increasing, a rigorous evidence base for birth centres is limited due to heterogeneity in design and overall quality of the available research to date [60]. Clearly, there is a need for more controlled studies on all aspects of birth centres including outcomes, cost effectiveness and maternal satisfaction within a Canadian context. However, the international research to date and the emerging Canadian data strongly support the establishment of birth centres as a safe and satisfying choice for families and care providers within an overall framework of maternal and newborn care. The lack of current Canadian data need not be a deterrent to efforts to establish birth centres as a response to the need for change within the context of maternity care reform in Canada particularly in light of the international evidence that supports birth centres as a safe and cost effective model of maternity care. In summary, the 2004 systematic review of free-standing midwifery-led birth centres in England, the USA and Germany concluded that: As a model, the free-standing, midwife-led unit is a small but growing phenomenon in many countries. Although results of existing research cannot be generalized, they do indicate that no a priori reason can be proposed to reject care in free-standing, midwife led units on the grounds of adverse outcomes. We concur with the argument that says because these women are at low obstetric risk; these environments are safe unless proved harmful. In addition, the findings raise a question about the risk of increased morbidity for women who fulfill standard criteria for such units, but who labor and give birth in centralized obstetric units [17, p. 228] E. Planning Assumptions This proposal is based on the following assumptions:
The South Winnipeg Maternity and Birth Centre will be an out-of-hospital site where midwives will provide prenatal, perinatal and postnatal primary care with a woman-centred and culturally diverse approach. Consistent with Health Canada’s Guidelines for Family Centred Maternity Care, childbirth will be treated as a social and cultural event - a celebration [16].
As the first out-of-hospital centre for maternity care in Manitoba, it is imperative that the Centre develop excellent quality assurance mechanisms. These will be developed using existing standards (e.g. the College of Midwives of Manitoba Standard for Planned Out of Hospital Births, Consultation and Transfer of Care and the standards of the American Association of Birth Centres). As well, we propose implementing a suggestion from Dr. William Fraser, author of the evaluation of the Quebec birth centre implementation project, that a birth centre advisory committee, made up of midwives, obstetricians, family physicians, paediatrics, and others be established to review outcomes on an ongoing basis. A process evaluation is planned. The Quality Assurance Plan is described in more detail under Risk Management below.
The Maternity and Birth Centre Model of Care includes:
F. Proposed Services at the South Winnipeg Maternity and Birth Centre The Maternity and Birth Centre will offer care for women and their babies and families during the childbearing years. Direct ServicesThe Centre will offer the following direct services: • Prenatal care and Education • Intrapartum Care • Immediate Postpartum Care (minimum of 4 hours, average of 12 hours) • Postpartum Care for mother and baby. • Home and Birthing Centre based postpartum checks • Breastfeeding support • Parenting Support And Education • Early intervention and support for post partum stress and adjustment Primary Prenatal Care The Maternity and Birth Centre will offer a variety of options for prenatal care. For women planning to give birth at the Centre, care will be provided by their midwives using one of two models – either traditional individual prenatal care or group care using a Manitoba adaptation of the Centering Pregnancy® model. Group prenatal care models have been successfully implemented at, for example, the South Community Birth Program in Vancouver [28]. After the completion of an initial individual prenatal intake visit/evaluation, the program will have three care components: assessment, education and support. All of these will be done in a group setting, with one-to-one prenatal visits added as required. Because group prenatal care provides women with peer support, by delivering prenatal education and most prenatal care in groups, participating midwives will be able to provide care to more women. Standard individual prenatal care with a midwife will also be provided if this is preferred. Prenatal care at the Maternity and Birth Centre will also include tours of the labour and delivery units at the Health Sciences Centre and the “virtual tour” of the St. Boniface Hospital, in order to help women feel comfortable should they be transferred to the hospital. Matching of doulas/health interpreters with pregnant women would also occur at the Centre. This service is targeted to women who require linguistic and cultural interpretation or who needed supplemental social support during their labours. Women from South Winnipeg and others, who are not planning to use the Maternity and Birth Centre for their births or prenatal care, would be able to access prenatal education at the centre as well as the post natal education and support services at the Maternity and Birth Centre. Childbirth/Intrapartum Care The Maternity and Birth Centre will be used by women who seek care from midwives and for whom an out-of-hospital birth would be a safe choice, but who choose not to have a home birth. It is anticipated that the majority of the clients of midwives working at the Maternity and Birth Centre will choose to give birth at the Centre. Like all WRHA midwives, those working at the Maternity and Birth Centre would also attend women in hospital and at home. In addition to serving the clients of the midwives on staff of the Maternity and Birth Centre, the Centre will be available to other midwives, whose clients are interested in giving birth at the Centre, on a first‑come, first‑served basis after initial intake process, and in the context of the Centre’s equity population goals. This would mean that women from other areas of Winnipeg, and from the surrounding areas, would have access to the Centre. Midwives may also work collaboratively with family physicians, whose patients want a Maternity and Birth Centre birth The birthing area of the Centre will not be staffed 24/7. Outside of regular working hours, staff will come in, to attend birthing women, on an as needed basis. However it is anticipated that even in year one, the birthing area will be in use most of the time. The proposed model is based on the model used in Québec and the UK and WRHA home birth practice. It assumes on continuous one-to-one support during labour, since the best evidence shows that this improves outcomes and reduces interventions [12]. Once labour begins, the following will occur:
Post partum assessments will be done at day one in the home, then either at the Centre, office or home per existing practice. Transfers to Specialist Care and to Hospitals The decision to consult with a specialist during pregnancy or to transfer to hospital care during active labour will be made in accordance with the College of Midwives of Manitoba’s Standard for Consultation and Transfer of Care (Appendix 2). Based on experience in other birth centres, it is expected that approximately 15% of women will leave the Centre to give birth in hospital either with their own transportation or if required by EMS. In order to facilitate intrapartum transfers by ambulance, the Maternity and Birth Centre will be located on a major transportation route. Note: The majority of these are non-urgent transports and done without ambulance supports, for example, as the result of a decision to move to hospital for pharmacological pain relief. Postnatal and Newborn Care Midwifery clients can attend the Maternity and Birth Centre for postnatal visits where appropriate. Of course, midwives will continue to visit women and their newborns at home. The Centre will also offer educational programs, lactation advice and support for new mothers and fathers. Parenting Support The Maternity and Birth Centre would offer support to new mothers and fathers, including lactation support. These services would be open to clients of the centre’s staff and others from the surrounding community. Mother/parent’s programming and “drop in” and post partum adjustment counselling services will be provided. The Centre would also be an ideal site for the Manitoba Healthy Baby Program. Other Services to be offered at the Maternity and Birth CentreAs an integrated component of the Winnipeg and Manitoba maternity care systems, the Maternity and Birth Centre will also offer the following other services.
Organizational StructureIn keeping with the tradition of community based and innovative approaches the Maternity and Birth Centre will be a program of the Women’s Health Clinic (WHC) and report to a community board. The service will be added to the existing service purchase agreement with the WRHA. Like other midwives in the WRHA, those working at the Centre would be employees of the WRHA. The midwives will report through the WRHA’s Clinical Midwifery Specialist. The Centre will be guided by an Advisory Committee made up of birthing women and their partners, midwives, family physicians, obstetricians and others. Centre staff will participate in relevant MB Health, WRHA Women’s Health, Primary Care and Tertiary program committees. On an annual basis, a community consultation will also be held. Staff of the Centre will report to the Program manager who will report to WHC Executive Director. Space, Design and Location1. Location The Centre will be close to major Winnipeg bus routes, to accommodate women and families who rely on public transit in the South of the city. The location will facilitate ease of transport to tertiary care facilities. It will have adequate parking available for clients and practitioners. It will be in a safe, diverse neighbourhood, with other amenities conveniently nearby. The presence of trees and quiet is necessary. It will be close to major transport route for ambulance access. Currently the area of Bishop Grandin Blvd. and Pembina Hwy is being explored. 2. Design Considerations The
overall desired ambiance and appearance The Birthing area should be separated from other areas of the Centre. The design of the Birthing area should encourage activity during labour through a wide circular walkway and open spaces such as a central courtyard with natural light or a sunroom with out door access. The Birthing rooms should be soundproofed so women wanting privacy aren’t disturbed by the noise of others, or feel free to make noise of their own. The Birthing Rooms should accommodate large beds, chairs with ottomans, pillows and other furniture to allow women to try different positions during labour and birth The design for the Birthing Centre building will meet standards for universal accessibility. Renovations will be consistent with Manitoba’s commitment to environmentally sustainable building, and will meet or exceed the LEED silver standards. It will meet the proposed “Green Building Policy for Government of Manitoba Funded Projects” [52]. 3. Space Requirements Birthing Area:
(separated from pre/post natal area by locking doors.)
§ Birthing Rooms: increased sound control to enhance privacy, individual temperature and light control. Each room should have a double bed with a firm mattress with a large tub/Jacuzzi, large chair, bassinet, cupboard, counter, storage, own bathroom, with a shower with a seat. Birthing rooms should be large enough to accommodate the woman, midwife, second attendant and doula, as well as partners, friends or relatives whom the woman wants with her. § Clean utility/Medical equipment in room close to birthing rooms. Sink, cupboards, desk with computer and charting area, where birth rooms can all be seen § Circular walkway leading to a central conservatory or sunroom § Family lounge with link to kitchen § Exit with wheel chair and stretcher capacity. Cloak room and boot racks
§
midwifery and second attendant call rooms Pre/Post Natal Area- comfortable, casual, quiet § Health Education/Meeting Rooms (2) § Round Room - small group and ceremony room for traditional smudging ceremony § Child Care Area § Midwifery Offices ( 2 midwives per office) § Examining rooms (3 with beds and 1 with examining table) § Counselling room/ en-suite office § Student, Health educators, doulas offices § Family Practice Space- two examining rooms and office space
§
Students area – for KOBP midwives, students,
physicians, nurses from Northern Man. 3 bedrooms and shared sitting area Shared Areas § Reception and waiting area, cloak room § Administration § Staff Room with small kitchen or close to birthing area kitchen G. Staffing
H. Impact Analysis Funding This proposal is for a new maternity care service in Winnipeg. No existing WRHA staff or budget will be transferred. Therefore additional resources will be needed to support the new centre Innovation and Demonstration While birth centres are well established, and growing, in other jurisdictions, this will be the first facility for planned out of hospital births in Manitoba. The Centre will therefore have well-developed risk management, quality assurance and evaluation plans. Alignment with Manitoba’s Women’s Health Strategy In 2000, the Minister of Health and the Minister
Responsible for the Status of Women jointly published Manitoba’s
Women’s Health Strategy [22]. In the Strategy gender
is recognized as a determinant of health. Identifying gender as a
determinant of health along with income, education, social support and other
health determinants was an important step in recognizing that the health
needs of women and men are different. The Centre will directly address many of the Goals of the Strategy, as described below. 1. To reduce risk factors that contribute to the
poor health of many women 2. To support the development of a health system that is sensitive and responsive to women's health This Maternity and Birth Centre is proposed in response
to the expressed desire of Winnipeg women for an alternative to home and
hospital births. The Centre’s mandate includes providing training
opportunities for new maternity care providers and continuing education
training in low-risk birth for established professionals.
4. To promote a wellness model 6. To build broad understanding that women’s health status includes their physical, emotional and mental health As part of the WHC’s broad mandate is to build understanding of social and gender differences and impact on women, the staff of the Maternity and Birth Centre will strive to provide woman centered care with the understanding that women’s health is about much more than their pregnancy. Woman-centered care incorporates issues that extend beyond traditional medical interventions, placing health in its broader context of the social determinants of health, such as income, education, social support and access to suitable housing. I. Risk Management and Quality Assurance Ongoing Quality Assurance will be the responsibility of the Program Manager and the Clinical Director (a senior midwife). Quality indicators will be regularly reviewed by the staff of the Centre, midwives, WHC management and board and reported to the WRHA. An implementation evaluation is planned. A birth centre advisory committee, made up of midwives, obstetricians, family physicians, paediatrics, emergency services, birth centre clients, WHC board members and other stakeholders will be established. This group will provide input into operating policy and programs and review outcome statistics. As well, we propose the development of a cross-region low risk maternity care database that would review and compare care across the region. The Birth Centre will adhere to: · The American Association of Birth Centres Standards for Birth Centres [20]. · The principles of the Mother-Friendly Birth Initiative [64] · The College of Midwives of Manitoba standards for Out Of Hospital Births and Consultation and Transfer of Care [31, 32]. · WRHA critical occurrence and other quality assurance reporting for maternity care. · WRHA standards on infection control and body fluid management. · Manitoba Health’s Provincial Standard for the Provision of Midwifery Care in Manitoba, which states in part that “each RHA shall strive to increase midwifery services to priority population clients to a least 50% Priority populations are defined for the purpose of the standard as Women who are: single, adolescent (<20 years), immigrant, newcomer, aboriginal, socially isolated, poor or at risk for other reasons" [5]. · Health Canada Family-Centred Maternity and Newborn Care: National Guidelines [16] · The Centre will seek accreditation under the WHO/UNICEF Baby-Friendly TM Hospital Initiative and designation as a Mother Friendly facility [29, 30] It will maintain excellent and ongoing relationships with Emergency Services.
1.
World Health Organization. 2005. The World Health Report 2005: Make
every mother and child count. Geneva: World Health Organization. 219 p.
2.
CANSIM Table 102-00301 - Infant mortality, by sex and birth weight,
Canada, provinces and territories, annual. [Internet]. Ottawa: Statistics
Canada.; c2005 [cited 2005 Nov 28]. Available from
http://cansim2.statcan.ca/cgi-win/CNSMCGI.EXE
Ontario Maternity Care Expert
Panel. 2006. Executive Report - Emerging Crisis, Emerging Solutions.
Toronto, ON: Ontario Women's Health Council. 29 p.
4.
Primary Maternity Health Care. [Internet]. Ottawa, ON:
Multidisciplinary Collaborative Primary Maternity Care Project. [cited 2006
Sep 12]. Available from
http://www.mcp2.ca/english/documents/PrimaryMaternityHealthCareDefinition-Final_000.pdf
5.
Manitoba Health. 2002. Standard for the Provision of Funded
Midwifery Care in Manitoba.
6.
Who We Are: WHC Model Of Care. [Internet]. Winnipeg, MB: Women's
Health Clinic.; c2005 [cited 2006 Aug 26]. Available from
http://www.womenshealthclinic.org/WHC_model.html
7.
Model of Practice. [Internet]. Winnipeg, MB: College of Midwives of
Manitoba. [cited 2006 Aug 26]. Available from
http://www.midwives.mb.ca/StandardsAndPolicies/Std-PlannedOutOfHospitalBirth.html
8.
SOM Recherches et
Sondages. 2005. Études sur les attentes des femmes en âge de procréer à
l’égard des services de périnatalité Rapport final Présenté à Ministère de la
Santé et des Services sociaux. Montréal: SOM Recherches et Sondages.
55 p.
9.
Ministère De La
Santé et des Services sociaux. 2006. Projet de Politique de périnatalité:
Document De Travail. Québec: Québec Ministère de la Santé et des Services
sociaux. 117 p.
10.
Winnipeg Regional
Health Authority. 2006. Midwifery Program Quarterly Reports to Manitoba
Health.
11.
Health Canada. 2003. Canadian Perinatal Health Report 2003. Ottawa,
ON: Minister of Public Works and Government Services. 273 p.
12.
Hodnett ED, Gates S, Hofmeyr GJ,
Sakala C. 2003. Continuous support for women during childbirth. Cochrane
Database of Systematic Reviews (3): Art. No.: CD003766 DOI:
10.1002/14651858.CD003766
13.
Canadian Institute for Health
Information. 2004. Giving Birth in Canada: Providers of Maternity Care.
Ottawa, ON: Canadian Institute for Health Information. 38 p.
14.
Canadian Institute For Health Information. 2004. Giving Birth in
Canada: A Regional Profile. Ottawa, ON: Canadian Institute for Health
Information. 68 p.
15.
Royal College of Midwives. 2004. Birth Centres – Position
Statement. London: Royal College of Midwives 2 p.
16.
Health Canada. 2000.
Family-Centred Maternity and Newborn Care: National Guidelines. Ottawa, ON:
Minister of Public Works and Government Services
17.
Walsh D, Downe S. 2004.
Outcomes of Free-Standing, Midwife-Led Birth Centers: A Structured Review.
Birth 31(3 ):222-9.
18.
Department of Health. 1993. Changing Childbirth. London: The
Stationery Office Books.
19.
Department Of Health . 2004. National Service Framework for Children,
Young People and Maternity Services: Maternity Services. London: Her
Majesty's Stationery Office. 52p.
20.
American Association of Birth Centers . 2003. Standards for Birth
Centers. Perkiomenville, PA: American Association of Birth Centers. 24 p.
21.
Barnes P, Dossey M. 1999. Triage Issues In An Out-Of-Hospital Birth
Center. Journal of Nurse Midwifery 44(5):458-70.
22.
Manitoba Health and Manitoba Women’s Directorate. 2001. Manitoba
Women’s Health Strategy.
23.
Jackson D. 2003. Outcomes, Safety, and Resource Utilization in a
Collaborative Care Birth Center Program Compared With Traditional
Physician-Based Perinatal Care. American Journal of Public Health
93(6):999-1006.
24.
Rooks J., Weatherby EL, Ernst EK. 1989. Outcomes of care in birth
centers. The National Birth Center Study. New England Journal of Medicine
321(26): 1804‑1811
25.
Coyle C, Hauck Y,
Percival P. 2001. Ongoing
relationships with a personal focus: mothers' perceptions of birth centre
versus hospital care. Midwifery 17: 171-181
26.
Walsh D. 2006. Subverting the assembly-line: Childbirth in a
free-standing birth centre. Social Science and Medicine 62: 1330-1340
27.
Kirkham M. 2003. Birth Centres as an Enabling Culture. In: Kirkham
M, editor. Birth Centres: A Social Model of Maternity Care. London: Books
for Midwives. p 249-261
28.
South Community Birth Program. 2006. Final Report: 2003 - 2006
Primary Health Care Transition Fund Program. Vancouver, BC: South Community
Birth Program. 40 p.
29.
Baby Friendly Initiative. [Internet]. Winnipeg, MB: Manitoba
Health. [cited 2006 Nov 9]. Available from
http://www.gov.mb.ca/health/nutrition/bfi2.html
30.
Coalition To Improve Maternity Care Services . 1996. The
Mother-Friendly Childbirth Initiative. Ponte Vedra Beach, FL: Coalition for
Improving Maternity Care Services. 4 p
31.
Standard for Planned Out of Hospital Birth. [Internet]. Winnipeg,
MB: College of Midwives of Manitoba. [cited 2006 Aug 26]. Available from
http://www.midwives.mb.ca/StandardsAndPolicies/Std-PlannedOutOfHospitalBirth.html
32.
Standard for Consultation and Transfer of Care. [Internet].
Winnipeg, MB: College of Midwives of Manitoba. [cited 2006 Aug 26].
Available from
http://www.midwives.mb.ca/StandardsAndPolicies/Std-ConsultationAndTransferOfCare.html
33.
Standard for Use of a Second Attendant. [Internet]. Winnipeg, MB:
College of Midwives of Manitoba. [cited 2006 Aug 26]. Available from
http://www.midwives.mb.ca/StandardsAndPolicies/Std-UseOfSecondAttendant.html 34. |
home like atmosphere in which to give birth. 
Mothers, the newborn and children represent the well being
of a society and its potential for the future. Their health needs cannot be
left unmet without harming the whole of society… Whereas mothers and
children were previously thought of as targets for well-intentioned
programs, they now increasingly claim the right to access quality care as
an entitlement guaranteed by the state. In doing so, they have transformed
maternal and child health from a technical concern into a moral and political
imperative. [1 page xiii]
The Centre will operate with a philosophy based on the
Women’s Health Clinic’s Model of Woman Centred Care and the
College of Midwives of Manitoba’s Model of Practice [6, 7].
by midwives, and, when required, by trained doulas (labour companions),
who share a common first language and/or culture with the birthing woman;