Midwifery in Manitoba Kate Abbott, RM

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1 Midwifery in Manitoba Kate Abbott, RM Relationships with commercial interests: Grants/Research Support: none Speakers Bureau/Honoraria: none Consulting Fees: none Other: Employee of Winnipeg Regional Health Authority

2 Objectives Overview of Midwifery Regulation in Manitoba Overview of WRHA Midwifery Program Birth Centre History and Operations Birth Centre Outcomes Innovative Midwifery Practice

3 Midwifery Across Canada Midwifery is regulated in 8 provinces and 2 territories: Ontario (1994) British Columbia (1998) Alberta (1998) Quebec (1999) Manitoba (2000) Northwest Territories (2005) Saskatchewan (2008) Nova Scotia (2009) New Brunswick (2010) Nunavut (2011) Regulation is being considered in Prince Edward Island, Newfoundland & Labrador, and Yukon Territory Currently over 1,000 midwives practicing in Canada High degree of similarity in the midwifery model of practice across Canada

4 A Brief History of the Path to Midwifery Regulation in Manitoba In the 1980's and early 1990's a succession of committees recommended that the Manitoba government recognize the profession of midwifery as an autonomous profession. The Midwifery Implementation Council was established in TheMidwifery and Consequential Amendments Actwas passed in June 12, 2000 The Midwifery Act was proclaimed, establishing midwifery as a self-regulating profession. June 13, 2000 the first 13 midwives were registered. Currently there are 44 practicing midwives in Manitoba.

5 Practice Framework The Midwifery Model of Care Philosophy includes pregnancy as a state of health & woman-centered care. Autonomy Community Input Informed Choice Continuity of Care Choice of Birth Setting Two Attendants at Each Birth Collaborative Care Accountability and Evaluation Accessibility and Equity Research Educators

6 The Midwifery Act Assented to June 28, 1997 Midwife as primary health care provider A midwife may, in accordance with this Act and the regulations, engage in the practice of midwifery as a primary health care provider who a) is directly accessible to clients without referral from a member of another health profession; b) is authorized to provide health services within the practice of midwifery without being supervised by a member of another health profession; and c) consults with other health professionals, including physicians, if medical conditions exist or arise during pregnancy that may require management outside the scope of the practice of midwifery.

7 The Midwifery Act Assented to June 28, 1997 Included practices In the course of engaging in the practice of midwifery, a midwife may a) order and receive reports of screening and diagnostic tests designated in the regulations; b) prescribe and administer drugs designated in the regulations; and c) perform minor surgical and invasive procedures designated in the regulations.

8 Common Consultations with Family Physician Midwives are not able to manage or treat some common complications of pregnancy, so may seek consultation with the patient s family doctor. Examples include: Hypothyroid Management of preexisting depression or anxiety Treatment of urinary tract infection Prescription of antivirals for management of HSV Non-obstetrical complaints, such as RTIs

9 Discussions, Consultations and Transfers of Care Standards set by the college require consultation with another care provider or transfer of care to a physician in particular situations. Women with serious medical conditions noted on initial history require an immediate transfer of care to a physician, and therefore are not likely to be accepted into midwifery care. Should a complication arise during the pregnancy, labour, postpartum or neonatal period a shared-care approach may be taken. Should a transfer of care be required, the midwife remains in a supportive role.

10 Midwifery in the WRHA A midwife s caseload is courses of care per year Schedule of visits: prenatal, 3-4 first week pp, 2, 4, 6 weeks Central intake process Caseloads full (50% refused due to maximum capacity) MB Health requirement to have 50% priority populations (immigrant, teens, socially at risk and first nations)

11 What the Birth Centre Offers 1. Community Programming (accessible to entire city) includes Coping with Change (postnatal), health education, drop-in parent/infant programming, child minding and meeting space 2. Primary maternity care services -on site practice of 12 midwives but all WRHA midwives may see clients at the center (7090 visits as of December 2013) 3. 24/7 Accessible Birth Services 324 admissions and 255 completed births as of December Birth services are accessible to clients of WRHA midwives who currently provide out of hospital birth

12 Out of Hospital Birth Increasing research available on OOH birth in Canadian midwifery model Studies to date from BC and Ontario indicate outcomes are similar (and sometimes improved!) for appropriately selected mom and baby in OOH setting with registered midwife Research from USA of limited use (use of birth certificates for data, no consistency in midwifery training and practice between states) More research is needed, however a large randomized control trial will likely never be possible

13 Out of Hospital Birth Only available to low risk women; risk status constantly reevaluated Ability to transport to hospital quickly is a requirement Two midwives at each birth Pain relief options- 1:1 support/showers/tubs. N2O2 at birth center. Intermittent auscultation only Discharge at 4-6 hours to be followed by midwife

14 Birth Centre Eligibility Women with very low risk pregnancies Derived from research/desire to maximize best outcomes in first years (multiple sources of scrutiny!) Generally based on CMM Standard for out of hospital birth Careful initial selection/on-going assessment throughout pregnancy Midwives submit assessment checklist at 16 and 36 weeks No VBAC at present

15 Overall rate -22% Transfers/Transports from Birth Centre 17% of transports are non-urgent (non-progressive labour, pain relief, meconium in first stage with normal FH) Emergencies include PPH/retained placenta, meconium in second stage, abnormal FH, neonatal concerns EMS Calls that do not result in transport not included in above statistics (bradycardiaor meconium in second stage, but baby born vigorous prior to transport) Majority of transports are non-urgent for primigravidas. Multigravida have a higher rate of emergency transport, but fewer transports overall. Consistent with transport rates in Canadian research of OOH births

16 Profile of Midwifery Births Birth Centre % Home % HSC % St. Boniface % Totals January 13 24% 2 4% 20 37% 19 35% 54 February 7 18% 1 3% 9 23% 23 58% 40 March 13 25% 6 11% 11 20% 23 43% 53 April 11 20% 8 14% 17 30% 20 36% 56 May 16 30% 1 2% 14 26% 23 43% 54 June 11 22% 2 4% 20 40% 17 37% 50 July 9 28% 8 26% 6 19% 9 29% 32 August 8 20% 3 7% 16 41% 12 31% 39 September 10 26% 2 5% 19 49% 8 21% 39 October 9 29% 3 10% 14 45% 5 16% 31 November 8 28% 0 0% 14 48% 7 24% 29 December 10 53% 0 0% 5 26% 4 21% 19 Totals: % 36 8% % % 496 *

17 Mount Carmel Clinic We meet you where you are at. No judgment here. Just care. Where are they? Point Douglas Downtown Inkster Young Less education Single More poverty/eia Aboriginal More violence More STI s More addictions More incarceration More CFS involvement Less stable housing Less food security Less breastfeeding Less homebirth More multi-agency, collaborative involvement More heart!

18 Mount Carmel Midwives Meeting the needs of community: PIIPC Partners in inner-city integrated prenatal care Research project aimed at reducing inequities in use of prenatal care Four initiatives being implemented and evaluated: 1. Community based Prenatal Care initiative 2. Street outreach initiatives 3. Facilitated access 4. Social marketing initiative

19 Mount Carmel Midwives Social Marketing: a campaign consisting of posters in transit shelters, prenatal passports, community posters, radio advertisements, a campaign website and an info phone line

20 Out of Hospital Births Canadian Research Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, : a retrospective cohort study.hutton EK, ReitsmaAH, Kaufman K. Birth Sep;36(3): Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. Janssen PA, SaxellL, Page LA, Klein MC, Liston RM, Lee SK. CMAJ Sep 15;181(6-7): Erratum in: CMAJ Oct 27;181(9):617.

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