Perinatal Health Report 2009–2010

Perinatal Health Report 2009–2010 South East and Champlain — LHINs 10 & 11 August 2011 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. South East and Champlain – LHINs 10 & 11. Ottawa ON, 2011.
BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 1 TABLE OF CONTENTS List of Figures ……………………………………………………………………………………………………............ Preface ………………………………………………………………………………………………………………………… Acknowledgements ……………………………………………………………………………………………………… About the Better Outcomes Registry & Network (BORN Ontario) ………………………………… Executive Summary ……………………………………………………………………………………………………… Introduction ………………………………………………………………………………………………………………... Methods ………………………………………………………………………………………………………………………. Chapter 1 Profile of South East and Champlain LHIN Region and Obstetrical Population Introduction …………………………………………………………………………………………... Choice of birthplace ……………………………………………………………………………….. Maternal Age ………………………………………………………………………………………….. Chapter 2 Pregnancy ………………………………………………………………………………………………. Chapter 3 Maternity Health Service Issues Level of Care …………………………………………………………………………………………… Maternal Inter‐hospital Transfers …………………………………………………………… Chapter 4 Birth Type of Care Provider at Delivery …………………………………………………………... Fetal Surveillance …………………………………………………………………………………… Induction of Labour ……………………………………………………………………………….. Type of Delivery …………………………………………………………………………………….. Elective Repeat Cesarean Delivery …………………………………………………………. Pain Management in Labour and Birth …………………………………………………… Fetal Mortality ………………………………………………………………………………………. Preterm Birth ……………………………….……………………………………………………….. Fetal Growth – Small for Gestational Age and Large for Gestational Age Multiple Birth ………………………………………………………………………………………… Chapter 5 Postpartum and Newborn ……………………………………………………………………… Breastfeeding ………………………………………………………………………………………… Chapter 6 Maternal and Newborn Screening ………………………………………………………….. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 4 8 9 10 11 14 15 19 27 29 37 43 47 50 52 56 63 72 77 85 86 91 95 102 106 110 2 APPENDICES A B C D E F G BORN Ontario Contact Information ………………………………………………………………….... 117 Accessing BORN Ontario Data …………………………………………………………………………….. 118 Number of total hospital births, by hospital site and fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 ……………………………………. 119 Maternal pre‐existing health condition categories in BORN–Niday Perinatal Database………………………………………………………………………………………………………………. 120 Obstetrical complication categories in BORN–Niday Perinatal Database …………….. 121 Hospital sites and level of care, South East and Champlain (SEC) LHIN Region ……. 123 Intrapartum complication categories in BORN–Niday Perinatal Database …………… 124 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 3 LIST OF FIGURES Chapter 1 Figure 1.1 Figure 1.2 Figure 1.3 Figure 1.4 Figure 1.5 Figure 1.6 Figure 1.7 Figure 1.8 Figure 1.9 Figure 1.10 Figure 1.11 Figure 1.12 Figure 1.13 Chapter 2 Figure 2.1 Figure 2.2 Figure 2.3 Figure 2.4 Chapter 3 Figure 3.1 Profile of South East and Champlain LHIN Region and Obstetrical Population Number of women who gave birth, by LHIN of birth and fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Number of women who gave birth, by LHIN of maternal residence and fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Number of total births, by LHIN of birth and fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Number of total births, by LHIN of maternal residence and fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Proportion of women who had a hospital birth in their LHIN of residence, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Proportion of women who had a hospital birth in their LHIN of residence, by LHIN of maternal residence, South East and Champlain (SEC) LHIN Region, 2009–2010 Number of women in midwifery care that gave birth at home, by LHIN of maternal residence, South East and Champlain (SEC) LHIN Region, 2009–2010 Distribution of maternal age, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Proportion of women who were <20 years at delivery, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Proportion of women who were ≥35 years at delivery, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Distribution of parity, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Proportion of women who were ≥35 years and nulliparous at delivery, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Proportion of women who were ≥35 years and nulliparous at delivery, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Pregnancy Proportion of women who did not attend an antenatal visit with a health care provider during the first trimester, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Proportion of women with pre‐existing health conditions, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Proportion of women with obstetrical complications during pregnancy, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Rate of assisted conception, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Maternity Health Service Issues Distribution of live births at each level of care, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 4 Figure 3.2 Figure 3.3 Figure 3.4 Chapter 4 Figure 4.1 Figure 4.2 Figure 4.3 Figure 4.4 Figure 4.5 Figure 4.6 Figure 4.7 Figure 4.8 Figure 4.9 Figure 4.10 Figure 4.11 Figure 4.12 Figure 4.13 Figure 4.14 Figure 4.15 Figure 4.16 Figure 4.17 Figure 4.18 Figure 4.19 Distribution of live births at each level of care, by gestational age at birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Distribution of live births 24–36 weeks at each level of care, by gestational age at birth and fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Proportion of maternal inter‐hospital transfers to a higher, equivalent or lower level of care, South East and Champlain (SEC) LHIN Region, 2009–2010 Birth Distribution of type of health care provider who attended the hospital birth, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Fetal surveillance methods during labour, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Rate of auscultation only for fetal surveillance during labour, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Distribution of type of labour, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Rate of labour induction, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Rate of labour induction, by hospital level of care, South East and Champlain (SEC) LHIN Region, 2009–2010 Proportion of women who underwent labour induction, by gestational age at birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Indication for induction of labour, South East and Champlain (SEC) LHIN Region, 2009–
2010 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, South East and Champlain (SEC) LHIN Region, 2009–2010 Rate of operative vaginal delivery, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Rate of operative vaginal delivery, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Rate of cesarean delivery, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Rate of cesarean delivery, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Rate of cesarean delivery, by hospital level of care, South East and Champlain (SEC) LHIN Region, 2009–2010 Rate of cesarean delivery, by Robson classification groups, South East and Champlain (SEC) LHIN Region, 2005–2006 and 2009–2010 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, South East and Champlain (SEC) LHIN Region, 2009–2010 Rate of episiotomy or 3rd/4th degree perineal laceration, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Rate of episiotomy or 3rd/4th degree perineal laceration, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Proportion of women with intrapartum complications, by fiscal year, South East and BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 5 Figure 4.20 Figure 4.21 Figure 4.22 Figure 4.23 Figure 4.24 Figure 4.25 Figure 4.26 Figure 4.27 Figure 4.28 Figure 4.29 Figure 4.30 Figure 4.31 Figure 4.32 Figure 4.33 Figure 4.34 Figure 4.35 Figure 4.36 Chapter 5 Figure 5.1 Figure 5.2 Figure 5.3 Figure 5.4 Figure 5.5 Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Rates of pharmacologic pain management among women who had a vaginal live birth, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Rates of pharmacologic pain management among women who had a vaginal live birth, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Rates of pharmacologic pain management among women who had a vaginal live birth, by hospital level of care, South East and Champlain (SEC) LHIN Region, 2009–2010 Rates of pharmacologic pain management among women who had a cesarean live birth, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Rates of pharmacologic pain management among women who had a cesarean live birth, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Rates of pharmacologic pain management among women who had a cesarean live birth, by hospital level of care, South East and Champlain (SEC) LHIN Region, 2009–2010 Length of second stage of labour among women with a vaginal birth, by parity, South East and Champlain (SEC) LHIN Region, 2009–2010 Fetal mortality rate ≥500 grams, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Rate of preterm birth, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Rate of preterm birth, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Rate of preterm birth, by hospital level of care, South East and Champlain (SEC) LHIN Region, 2009–2010 Rate of preterm birth, by plurality and fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Rate of small for gestational age, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Rate of large for gestational age, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Rate of small for gestational age and large for gestational age, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Rate of multiple birth, by fiscal year, South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Rate of multiple birth, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Postpartum and Newborn Proportion of live births with a 5‐minute Apgar score below 4 or between 4 and 6, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Proportion of live births with a 5‐minute Apgar score below 4 or between 4 and 6, by hospital level of care, South East and Champlain (SEC) LHIN Region, 2009–2010 Proportion of live births requiring resuscitation, by gestational age, South East and Champlain (SEC) LHIN Region, 2009–2010 Proportion of live births with birth depression, by gestational age, South East and Champlain (SEC) LHIN Region, 2009–2010 Rate of exclusive breastfeeding at discharge among term live births, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 6 Chapter 6 Figure 6.1 Figure 6.2 Figure 6.3 Figure 6.4 Figure 6.5 Maternal and Newborn Screening Ratio of maternal multiple marker screening, by LHIN of residence, South East and Champlain (SEC) LHIN Region, 2009–2010 Proportion of women who were screened for Group B Streptococcus among women who delivered at ≥37 weeks of gestation, by LHIN of birth, South East and Champlain (SEC) LHIN Region, 2009–2010 Number of infants with newborn screening completed and proportion who screen positive, by LHIN of residence, South East and Champlain (SEC) LHIN Region, 2009–2010 Ratio of Parkyn screen completion, by LHIN of residence, South East and Champlain (SEC) LHIN Region, 2009–2010 Proportion of infants who received a Parkyn screen score of nine or greater, by LHIN of residence, South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 7 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) 10 & 11 for the South East and Champlain (SEC) LHIN Region. 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 (asprague@ottawahospital.on.ca). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 8 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 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 9 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 10 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. South East and Champlain LHINs provide obstetrical services to about 12% (12.5%) of Ontario residents who give birth in Ontario hospitals each year. Many factors influence the demands on both general and highly specialized obstetrical and neonatal services in the region. 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 South East and Champlain LHIN Region are summarized here: Population profile: 
About one in five women (20.6%) who gave birth in 2009–2010 in the South East and Champlain LHIN Region were 35 years of age or older. 
In 2009–2010, 30.7% of women had one or more pre‐existing health conditions and 35.2% had one or more obstetrical complications during their pregnancy, and both of these indicators increased in prevalence between 2006–2007 and 2009–2010. While some of the observed increase may be due to improvements in data capture in the region, an underlying true increase cannot be ruled out. 
In 2009–2010, the rate of preterm birth in the South East and Champlain LHIN Region was 9.5% and increased slightly between 2005–2006 and 2009–2010 (from 8.5% to 9.5%). The corresponding number of babies born at <37 weeks of gestational age in 2009–2010 was 1,630. The rate of preterm birth was higher in this region that in the other regions of the province. 
Rates of small for gestational age (SGA) were very stable between 2005–2006 and 2009–2010 in the region. In 2009–2010, 7.3% of singleton live births were SGA. 
The multiple birth rate in the South East and Champlain LHIN Region in 2009–2010 was 4.0%, corresponding to 699 infants. Having contemporary information on characteristics of the maternal‐newborn population and monitoring trends in these characteristics is important for system planning. With the relatively high proportion of women giving birth at 35 years of age or older and high proportion of women with pre‐
existing health conditions and obstetrical complications, system planners and funders will need to project service needs. Intrapartum interventions: 
The rate of labour induction in the overall obstetrical population was 25.0% and in low‐risk nulliparous women was 33.0% in 2009–2010 in the South East and Champlain LHIN Region and no change in induction rates was observed between 2006–2006 and 2009–2010. 
The largest contributor to the overall rate of cesarean delivery of 28.9% was among women with a term singleton who had given birth by cesarean in a previous pregnancy. Reducing primary cesarean BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 11 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. Use of intrapartum interventions has important implications, since they affect service requirements in current and future pregnancies. Effectiveness: 
In 2009–2010, 89.1% 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 9.7% in the overall obstetric population and 18.4% 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 52.6% (4.5% at 37 weeks and 48.1% at 38 weeks). 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 South East and Champlain LHIN Region in 2009–2010, 13.9% of women (163 out of 1,168 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. 
62.4% of term live born babies were being exclusively breastfed at the time they were discharged from hospital (56.4% in South East and 64.9% in Champlain). A further 22.2% 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. 
A high proportion of women (93.8%) 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, BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 12 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.
BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 13 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 14 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. Total number of ON hospital births BORN DAD % captured by BORN Fiscal year 2004–2005 2005–2006 2006–2007 2007–2008 2008–2009 113,220 137,996 120,803 139,159 125,724 141,173 136,980 144,240 139,278 142,896 82.05% 86.81% 89.06% 94.97% 97.47% BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 15 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 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 16 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 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 17 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]. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 18 CHAPTER 1 PROFILE OF SOUTH EAST AND CHAMPLAIN LHIN REGION AND OBSTETRICAL POPULATION
Introduction The South East and Champlain (SEC) Region includes two Local Health Integration Networks (LHINs). The South East LHIN (LHIN 10)1 is comprised of the City of Kingston and the surrounding municipalities of Frontenac, Lanark, Leeds and Grenville, Lennox and Addington, Hastings, and Prince Edward, and covers a land area of 17,887.16 square km. The Champlain LHIN (LHIN 11)2 is comprised of the City of Ottawa and the surrounding municipalities of Renfrew County, North Lanark, North Grenville, and the Eastern Counties and covers a land area of 17,631.05 square km. Together, these two LHINs include an estimated population of 1.6 million. LHIN Number LHIN Name Population 10 11 South East Champlain 466,669 1,147,209 10 & 11 SEC REGION 1,613,878 Sources: Statistics Canada. 2007. South East Health Integration Network, Ontario (Code3510) (table). 2006 Community Profiles. 2006 Census. Statistics Canada Catalogue no. 92‐591‐XWE. Ottawa. Released March 13, 2007 [cited 23 Feb 2011]. Available from: http://www12.statcan.ca/census‐recensement/2006/dp‐pd/prof/92‐591/index.cfm?Lang=E. Statistics Canada. 2007. Champlain Health Integration Network, Ontario (Code3511) (table). 2006 Community Profiles. 2006 Census. Statistics Canada Catalogue no. 92‐591‐XWE. Ottawa. Released March 13, 2007 [cited 23 Feb 2011]. Available from: http://www12.statcan.ca/census‐recensement/2006/dp‐pd/prof/92‐591/index.cfm?Lang=E. In the fiscal year 2009–2010, the region had 15 hospital sites providing obstetric and newborn care services: two tertiary care sites, one Level II+ centre, two Level II hospitals and ten Level I hospitals (with a range of 40 to more than 1,400 births per year). In addition there is also a Level III neonatal intensive care unit at the regional Children’s Hospital for babies born at other sites and transferred after birth3 (see APPENDIX C for a complete list of all hospital sites). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 19 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 [accessed 28 Mar 2011]. Available from: http://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=13832. During this reporting period, the Perinatal Program of Eastern and Southeastern Ontario (PPPESO) was an active partner in the delivery of maternal‐newborn services in the SEC Region. During the past year PPPESO worked closely with the Champlain LHIN and its partners to launch the new Champlain Maternal Newborn Regional Program (CMNRP) in order to promote a sustainable and responsive maternal, newborn health care system within the region. The CMNRP is committed to continued collaboration with the South East LHIN and with BORN Ontario to facilitate partnerships, share data and support quality improvement strategies within the SEC Region. This report presents data for Ontario residents who gave birth in a hospital in either the South East LHIN or Champlain LHIN. Readers of previous regional reports produced by the former Perinatal Partnership Program of Eastern and Southeastern Ontario should note that the figures in this report include only residents of Ontario, and therefore will differ slightly from previous reports. Data tables that include all births in the region, regardless of province of maternal residence, are available from BORN Ontario. The hospital sites whose data are included in this report can be found in APPENDIX C. Women who resided in the SEC Region 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 SEC Region give birth in the LHIN in which they reside, there is some 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, 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 20 Figure 1.1 Number of women who gave birth, by LHIN of birth and fiscal year South East and Champlain (SEC) 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 Ontario women who gave birth in a hospital in the South East and Champlain (SEC) LHIN Region in 2005–2006 to 2009–2010. Notes: 1. The total number of women who gave birth in a SEC hospital by fiscal year was: 2005–2006: 16,212; 2006–2007: 16,485; 2007–2008: 16,488; 2008–2009: 17,010; 2009–2010: 16,994. 
The number of women who gave birth in a hospital in the South East and Champlain LHIN Region in 2009–2010 was 16,994. This represents 12.5% of the total number of Ontario women who gave birth in an Ontario hospital in 2009–2010 (136,223). On average, the Champlain LHIN had about three times as many births as the South East LHIN. 
Between 2005–2006 and 2009–2010, the total number of women who gave birth in a hospital in the South East and Champlain LHIN Region was very stable. 
The Champlain LHIN additionally provides maternal‐newborn care to residents from other Canadian provinces – primarily Quebec and Nunavut. In 2009–2010, 1,294 women from another jurisdiction gave birth in a hospital in the Champlain LHIN, increasing the total number of women who gave birth in this LHIN to 14,216. Over the five fiscal years reflected in Figure 1.1, between 7.5% and 9.1% of all women who gave birth in Champlain LHIN were from another province or territory.
BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 21 Figure 1.2 Number of women who gave birth, by LHIN of maternal residence and fiscal year South East and Champlain (SEC) 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 maternal residence Definition of indicator The number of women residing in each LHIN in the South East and Champlain (SEC) LHIN Region who gave birth in hospital in 2005–2006 to 2009–2010. Notes: 1.
2.
3.
The total number of women who resided in the SEC Region and gave birth in hospital by fiscal year was: 2005–2006: 16,232; 2006–2007: 16,477; 2007–2008: 16,508; 2008–2009: 17,021; 2009–2010: 17,032. A small number of women in each fiscal year who gave birth in a SEC hospital, but could not be mapped to a LHIN of maternal residence were excluded. It is possible that some of these women were residents of the region. The numbers presented in this graph may differ from previous 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 the SEC Region and gave birth in 2009–2010 was 17,032. This represents 12.5% of the total number of Ontario women who gave birth in an Ontario hospital in 2009–2010 (136,223). 
The total number of SEC residents with a hospital birth recorded in the database increased by 4.9% from 16,232 in 2005–2006 to 17,032 in 2009–2010. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 22 Figure 1.3 Number of total births, by LHIN of birth and fiscal year South East and Champlain (SEC) 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 total births (live births and stillbirths) to Ontario women in a hospital in the South East and Champlain (SEC) LHIN Region in 2005–2006 to 2009–2010. Notes: 1.
The number of total births in a SEC Region hospital by fiscal year was: 2005–2006: 16,506; 2006–
2007: 16,776; 2007–2008: 16,797; 2008–2009: 17,292; 2009–2010: 17,351. 
The number of total births (live births and stillbirths) in a hospital in the SEC Region in 2009–2010 was 17,351. This represents 12.5% of the total number of hospital births in Ontario in 2009–2010 (138,775). 
Between 2005–2006 and 2009–2010, the number of total births in a hospital in the SEC Region increased by 5.1% from 16,506 to 17,351. 
The number of total births at each hospital site in the South East and Champlain LHIN Region can be found in APPENDIX C. 
The Champlain LHIN additionally provides maternal‐newborn care to residents from other Canadian provinces – primarily Quebec and Nunavut. In 2009–2010, there were 1,326 births in Champlain LHIN hospitals to women from another jurisdiction, increasing the total number of births in this LHIN to 14,525. Over the five fiscal years reflected in Figure 1.3, between 7.5% and 9.1% of all hospital births in Champlain LHIN were to women from another province or territory. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 23 Figure 1.4 Number of total births, by LHIN of maternal residence and fiscal year South East and Champlain (SEC) 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 maternal residence Definition of indicator The number of total hospital births (live births and stillbirths) to residents of each LHIN in the South East and Champlain (SEC) LHIN Region in 2005–2006 to 2009–2010. Notes: 1. The number of total hospital births to women who resided in the SEC Region by fiscal year was: 2005–2006: 16,524; 2006–2007: 16,764; 2007–2008: 16,815; 2008–2009: 17,295; 2009–2010: 17,389. 2. A small number of births in each fiscal year were excluded because they occurred in a SEC hospital, but could not be mapped to a LHIN of maternal residence. It is possible that some of these births were to residents of the region. 3. The numbers presented in this graph may differ from previous 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 hospital births to women who resided in the SEC Region in 2009–2010 was 17,389. This represents 12.5% of the number of total hospital births in Ontario in 2009–2010 (138,775). 
The number of total hospital births to SEC residents recorded in the database increased by 5.2% from 16,524 in 2005–2006 to 17,389 in 2009–2010. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 24 Figure 1.5 Proportion of women who had a hospital birth in their LHIN of residence, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 Data source BORN Ontario (Niday Perinatal Database), 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 the South East and Champlain (SEC) LHIN Region in 2009–2010. 
Among the women who gave birth in a hospital in the SEC LHIN Region in 2009–2010, almost all (97.3%) were residents of the LHIN in which they gave birth. Across Ontario, 84.5% of women reside in the LHIN where they give birth. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 25 Figure 1.6 Proportion of women who had a hospital birth in their LHIN of residence, by LHIN of maternal residence South East and Champlain (SEC) LHIN Region, 2009–2010 Data source BORN Ontario (Niday Perinatal Database), 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 South East and Champlain LHIN Region, or in another Ontario LHIN outside the South East and Champlain LHIN Region), expressed as a percentage of the total number of residents in the South East and Champlain (SEC) LHIN Region who had a hospital birth in 2009–2010. Notes: 1. Women who gave birth in a SEC hospital and had incomplete address information or no fixed residential address were excluded from the figure. 
Among the women who resided in the South East and Champlain LHIN Region and gave birth in 2009–
2010, the proportion who delivered in a hospital in the same LHIN as they resided was 99.5% among residents of Champlain LHIN and 90.0% among residents of South East LHIN. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 26 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 27 Figure 1.7 Data source Number of women in midwifery care that gave birth at home, by LHIN of maternal residence South East and Champlain (SEC) LHIN Region, 2009–2010 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 South East and Champlain (SEC) LHIN Region 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 SEC Region in 2009–2010 was 422. This represents 2.4% of the total births to residents of the region (422 out of 17,389 hospital births + 422 home births) and 15.6% of the total number of home births under the care of a midwife in Ontario in 2009–2010 (422 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 residents of the region. 
Across the SEC Region, the median maternal age of women who gave birth at home under midwifery care in 2009–2010 was 32 years, 23.5% of women were pregnant for the first time (i.e., gravida=1) and 1.7% 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 in the SEC Region. Median birth weight was 3,572 grams. A high proportion of babies were being exclusively breastfed at three days following birth (94.3%). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 28 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 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 29 Figure 1.8 Distribution of maternal age, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 Data source BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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). 
60.8% of women who gave birth in the South East and Champlain 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 6.4% in South East LHIN and 3.2% in Champlain LHIN. 
The proportion of births to women 35 years of age and over in 2009–2010 in the SEC LHIN Region was 20.6%, similar to the overall background proportion of 21.4% in Ontario. The proportion of women who were ≥35 years at delivery was much lower in South East (13.2%) than Champlain LHIN (22.9%). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 30 Figure 1.9 Proportion of women who were <20 years at delivery, by fiscal year South East and Champlain (SEC) 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 <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 South East and Champlain LHIN Region who were <20 years of age remained fairly constant between 2005–2006 and 2009–2010. In 2009–2010, 4.0% (95% CI: 3.7–4.3) of women who gave birth were under the age of 20 years. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 31 Figure 1.10 Proportion of women who were >35 years at delivery, by fiscal year South East and Champlain (SEC) 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 >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 South East and Champlain LHIN Region who were >35 years of age remained fairly constant. In 2009–2010, 20.6% (95% CI: 20.0–21.2) of women who gave birth were >35 years. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 32 Figure 1.11 Distribution of parity, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 Data source BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital 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. 
42.6% of the women who gave birth in the South East and Champlain LHIN Region in 2009–2010 were first‐time mothers (i.e., parity = 0), slightly lower than the background rate for the province (44.1%). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 33 Figure 1.12 Proportion of women who were ≥35 years and nulliparous at delivery, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 Data source BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital 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 25.7% across the South East and Champlain LHIN Region. For Ontario as a whole, 27.7% of women 35 years of age or older who gave birth in 2009–2010 were nulliparous. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 34 Figure 1.13 Proportion of women who were ≥35 years and nulliparous at delivery, by fiscal year South East and Champlain (SEC) 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 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 in the South East and Champlain Region who were nulliparous (i.e., parity = 0) at the time they gave birth decreased slightly from 28.5% (95% CI: 26.9–30.1) to 25.7% (95% CI: 24.3–27.2). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 35 References 1.
South East LHIN. Our Communities [cited 04 Apr 2011]. Available from: http://www.southeastlhin.on.ca/Page.aspx?id=146&ekmensel=e2f22c9a_72_184_146_3. 2.
Champlain LHIN. About Our LHIN [Internet]. [cited 04 Apr 2011]. Available from: http://www.champlainlhin.on.ca/aboutourlhin.aspx?ekmensel=e2f22c9a_72_184_btnlink. 3.
Perinatal Partnership Program of Eastern and Southeastern Ontario (PPPESO). Annual Perinatal Statistical Report 2007/2008 [Internet]. Ottawa, Ontario: PPPESO; 2008 [cited 04 Apr 2011]. Available from: http://www.pppeso.on.ca/site/pppeso/NIDAY_Perinatal_Database_p484.html. 4.
5.
College of Midwives of Ontario. Indications for Planned Place of Birth. Toronto: CMO, 1994. 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. College of Midwives of Ontario. Indications for Mandatory Discussion, Consultation, and Transfer of Care. Toronto: CMO, 2000. 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 36 HAPTER REGNANCY
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 C
2 P
BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 37 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 South East and Champlain (SEC) LHIN Region, 2009–2010 *
*
*
Data source BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth Definition of The number of women who did not attend an antenatal visit with a health care provider during the first indicator 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. 
In 2009–2010, the proportion of women who did not attend a first trimester prenatal care visit was 6.7% in South East and 10.1% in Champlain. The proportion of records missing this information was 6.3% and 20.7%, respectively. For the province of Ontario overall, 14.1% of women did not attend a first trimester prenatal care visit (21.3% missing). 
The results for Champlain and for the province as a whole 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 38 Figure 2.2 Proportion of women with pre‐existing health conditions, by fiscal year South East and Champlain (SEC) 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 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. ** Estimate not shown because more than 30% of records had missing information. Notes: 1. A complete list of the pre‐existing maternal health condition categories collected by the database can be found in APPENDIX D. 
Data for 2005–2006 are not presented because more than 30% of records had missing information. 
In 2009–2010, the most common pre‐existing conditions were other (17.1%), chronic disease (e.g., asthma, hypertension, diabetes and heart disease – 11.0%) and psychiatric disorders/mental illness (6.2%). 
The proportion of women with one or more pre‐existing health conditions increased from 23.8% (95% CI: 23.0–24.5) in 2006–2007 to 30.7% (95% CI: 30.0–31.5) in 2009–2010. 
In 2006–2007, 2007–2008 and 2008–2009, the proportion of records missing this information was 23.6%, 18.6% and 12.9%, 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 (7.6% missing). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 39 Figure 2.3 Proportion of women with obstetrical complications during pregnancy, by fiscal year South East and Champlain (SEC) 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 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. ** Estimate not shown because more than 30% of records had missing information. Notes: 1. A complete list of the obstetrical complication categories collected by the database can be found in APPENDIX E. 
Data for 2005–2006 are not presented because more than 30% of records had missing information. 
In 2009–2010, the most common obstetrical complications were other (16.4%), hypertension (4.4%), gestational diabetes (3.9%) and intrauterine growth restriction (3.5%), followed by premature rupture of membranes (PROM – 3.2%). 
The proportion of women with one or more obstetrical complications during pregnancy increased from 30.1% (95% CI: 29.3–31.0) in 2006–2007 to 35.2% (95% CI: 34.5–36.0) in 2009–2010. 
In 2006–2007, 2007–2008 and 2008–2009, the proportion of records missing this information was 25.0%, 18.5% and 12.4%, 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 (8.3% missing). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 40 Figure 2.4 Rate of assisted conception, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 *
**
**
Data source BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth Definition of The number of women who used reproductive assistance for the current pregnancy, expressed as a indicator 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. 
1.5% of women who gave birth in the South East LHIN in 2009–2010 had used some form of reproductive assistance to achieve the current pregnancy. 
Data for Champlain LHIN and for the South East and Champlain LHIN Region as a whole are not presented because more than 30% of records had missing information. For Ontario, 18.0% of records had missing data for this variable, thus it is unclear whether the actual proportion of women who used reproductive assistance is higher or lower than indicated here. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 41 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 42 ATERNITY EALTH ERVICE SSUES
HAPTER 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 South East and Champlain LHIN Region (see summary below). A list of all 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. C
3 Level of care I II/II+ III M
H
S
I
Description Provide care for healthy mothers and infants >36 weeks’ gestation Provide care for mothers and infants ≥32 weeks’ gestation 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.1 Level of care designations are beneficial for several reasons:1 
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. 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.2 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.2 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.3 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.4 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 43 Figure 3.1 Distribution of live births at each level of care, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 Data source BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital 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 South East and Champlain LHIN Region 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. 
In the Champlain LHIN, slightly more than a third of live births took place in a Level II hospital (34.8%), followed by 24.3% in a Level II+ hospital, 22.6% in a Level III hospital and 18.3% in a Level I hospital. In the South East LHIN, about half of all live births took place in a Level I hospital (50.6%) and another half in a Level III hospital (49.4%). 
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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 44 Figure 3.2 Distribution of live births at each level of care, by gestational age at birth South East and Champlain (SEC) LHIN Region, 2009–2010 Data source BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of 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). Notes: 1. Due to small numbers, a more detailed breakdown of gestational age groups cannot be presented in this report. However, individual hospitals may access their own data for more in‐depth examination of gestational age in their live birth population. 
In 2009–2010, the proportion of live births that took place in a Level III hospital was highest among those infants born at <28 weeks of gestational age (83.1%) and decreased with increasing gestational age at birth to 27.8% in term live births (≥37 weeks). 
Close to half of infants (46.7%) born at <24 weeks’ gestation were born at a Level III hospital (7 out of 15 live births [data not shown in figure]). 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 45 Figure 3.3 Distribution of live births 24–36 weeks at each level of care, by gestational age at birth and fiscal year South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Fiscal year Level of care 2005–06 III II / II+ I 2006–07 III II / II+ I 2007–08 III II / II+ I 2008–09 III II / II+ I 2009–10 III II / II+ I 24–31 weeks (n=245) 84.9 10.2 4.9 24–31 weeks (n=211) 82.9 11.4 5.7 24–31 weeks (n=230) 83.0 8.3 8.7 24–31 weeks (n=216) 83.3 10.2 6.5 24–31 weeks (n=242) 82.6 12.8 4.5 Gestational age 32–33 weeks (n=146) 54.1 43.8 2.1 34‐36 weeks (n=992) 33.1 49.6 17.3 32–33 weeks (n=171) 48.5 43.9 7.6 34‐36 weeks (n=1,092) 33.8 50.8 15.4 32–33 weeks (n=170) 55.3 39.4 5.3 34‐36 weeks (n=1,104) 31.8 50.5 17.8 32–33 weeks (n=188) 50.0 46.3 3.7 34‐36 weeks (n=1,144) 30.3 48.3 21.3 32–33 weeks (n=191) 51.3 41.4 7.3 34‐36 weeks (n=1,182) 31.1 50.4 18.4 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 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). 
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, was consistently above 80% between 2005–2006 and 2009–2010 in the South East and Champlain LHIN Region. 
Among infants born between 32–33 weeks of gestational age, the optimal level of care is Level II or higher. Between 2005–2006 and 2009–2010, the majority of infants 32–33 weeks were born in a Level II or higher level hospital (consistently >90%). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 46 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.5 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.5 The availability of beds and human resources are often the reason for maternal transfers between hospitals with similar levels of care.5 Decisions to transfer involve consideration of the clinical issues, the expertise and resources available at both hospitals and travel conditions.6 The availability of skilled accompaniment during transfer may also influence this decision.5 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,2 it has been suggested that in utero transfer should be a primary goal whenever the benefits of transfer outweigh the risks.7 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.8 The availability of affordable accommodation for parents anticipating a prolonged stay away from their home community may address some of these concerns.2 It has also been noted that care providers should be attentive to the emotional needs of women who require maternal transfer.7 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 47 Figure 3.4 Proportion of maternal inter‐hospital transfers to a higher, equivalent or lower level of care South East and Champlain (SEC) LHIN Region, 2009–2010 Data source BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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. Women who were transferred from a NOS hospital in 2009–2010 are excluded from this analysis. 2. Women who were transferred from a hospital outside the SEC 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. 
There were a total of 186 maternal inter‐hospital transfers resulting in a delivery that occurred in a South East and Champlain Region hospital in 2009–2010, of which 44 (23.7%) were from a hospital outside of the SEC LHIN Region. The remaining 142 maternal transfers (82.3%) were between SEC hospital sites (data not shown in figure). 
Among the 142 maternal inter‐hospital transfers between hospital sites in the South East and Champlain LHIN Region, the majority (84.8%) were transferred to a hospital with a higher level of care. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 48 References 1.
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. 2.
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. 3.
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. 4.
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. 5.
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. 6.
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. 7.
Wilson AK, Martel MJ, Arsenault MY, et al. Maternal transport policy. J Obstet Gynaecol Can 2005;27(10):956–
63. 8.
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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 49 C
HAPTER 4 BIRTH 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 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 50 Figure 4.1 Distribution of type of health care provider who attended the hospital birth, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 Data source BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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). 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. Definition of indicator Notes: 
The majority of women in the South East and Champlain LHIN Region had an obstetrician attending their hospital delivery (83.4%). 
The proportion of women whose care provider was a family physician at the time of their hospital delivery was 11.4% among women who delivered in Champlain LHIN and 13.3% in South East LHIN. 
Midwives were the care provider at 3.6% of hospital births in the SEC Region 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 51 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 52 Figure 4.2 Fetal surveillance methods during labour, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 Data source Definition of indicator Notes: BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital 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). 1. For this indicator, EFM is comprised of the following values: EFM admission strip, intrapartum EFM (external) and intrapartum EFM (internal). 
Across the South East and Champlain LHIN Region, 46.3% of women received only electronic fetal monitoring (EFM) during labour. A further 42.8% of women were monitored with auscultation in combination with EFM. Taken together, 89.1% of women had EFM at some time during their labour. 
The proportion of women who received auscultation only during their labour was 5.9% in South East LHIN and 11.0% in Champlain LHIN. 
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), 40.2% received EFM alone and a further 40.3% received EFM in combination with auscultation (data not shown in figure). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 53 
The rate of auscultation only among low‐risk women was higher than in the overall obstetric population (18.4% compared with 9.7%, respectively). The rate of auscultation only among low‐risk women was 10.6% in South East LHIN and 22.4% in Champlain LHIN (data not shown in figure). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 54 Figure 4.3 Data source Definition of indicator Rate of auscultation only for fetal surveillance during labour, by fiscal year South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 BORN Ontario (Niday Perinatal Database), 2005–2006 to 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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 increased slightly from 6.8% (95% CI: 6.3–7.2) to 9.7% (95% CI: 9.2–
10.2). 
The rate of auscultation only among low‐risk women was higher than in the overall obstetric population, but also increased over the five fiscal years from 14.7% (95% CI: 13.4–16.2) in 2005–2006 to 18.4% (95% CI: 17.0–19.9) in 2009–2010. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 55 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 56 Figure 4.4 Data source Definition of indicator Distribution of type of labour, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital 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 South East and Champlain LHIN Region, 59.2% of women went into spontaneous labour, with only slight variation across the two LHINs. The rate of labour induction was 25.0% in the SEC Region and 25.2% in the province. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 57 Figure 4.5 Rate of labour induction, by fiscal year South East and Champlain (SEC) 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 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 25.9% (95% CI: 25.2–26.6) to 25.0% (95% CI: 32.5–33.7). Among those meeting the definition for standardized nulliparous women, the rates of labour induction were, on average, approximately 30% higher than in the overall obstetrical population. Over the five fiscal years, the rate of labour induction in this subgroup was quite stable, going from 32.5% (95% CI: 31.2–33.7) in 2005–2006 to 33.0% (95% CI: 31.7–34.2) in 2009–2010. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 58 Figure 4.6 Data source Definition of indicator 

Rate of labour induction, by hospital level of care South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of 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). 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 some variation by the hospital level of care designation. Approximately 23% of women who gave birth in a Level II or Level III hospital were induced (23.7% and 22.9%, respectively). Approximately 28% of women who gave birth in a Level II+ hospital underwent labour induction, and 26.5% who gave birth in a Level I 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 59 Figure 4.7 Data source Definition of indicator Proportion of women who underwent labour induction, by gestational age at birth South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of 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 (21.9%) and highest among the women whose pregnancies reached 41 weeks’ gestational age or greater (52.0%). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 60 Figure 4.8 Indication for induction of labour South East and Champlain (SEC) LHIN Region, 2009–2010 Indication Post dates Other – maternal PROM Other – fetal Intra‐uterine growth restriction/Small for gestational age Pre‐eclampsia Elective Oligohydramnios Maternal obstetrical conditions Large for gestational age Diabetes Pre‐existing maternal medical conditions Multiple gestation Poor biophysical score Non‐reactive NST Number of women (3,892) 1,168 792 418 392 Percent (%) of women who had induction of labour 30.0 20.3 10.7 10.1 365 9.4 228 217 177 168 147 145 71 44 34 17 5.8 5.6 4.5 4.3 3.8 3.7 1.8 1.1 0.9 0.4 Data source Definition of indicator Notes: BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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). 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 South East and Champlain LHIN Region, the leading indication for labour induction was post‐dates pregnancy (30.0%), followed by other–maternal reason (20.3%) and premature rupture of membranes (10.7%). Post‐dates pregnancy was the leading indication for labour induction in each SEC 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 61 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 South East and Champlain (SEC) 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 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). Definition of indicator 
Across the South East and Champlain LHIN Region in 2009–2010, 13.9% of women (163 out of 1,168 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 slightly higher proportion of women with a post‐dates indication for induction were <41 weeks’ gestation at delivery (18.0%). 
Although there was variability between the South East and Champlain 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 62 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 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 63 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 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 64 Figure 4.10 Data source Definition of indicator Rate of operative vaginal delivery, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital 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 SEC LHIN Region in 2009–2010, the rate of operative vaginal delivery was 14.4%, 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 rate of operative vaginal delivery in the two LHINs was approximately 74% higher than in the overall obstetrical population. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 65 Figure 4.11 Rate of operative vaginal delivery, by fiscal year South East and Champlain (SEC) 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 The number of women who had a vaginal delivery that was assisted by means of forceps and/or indicator 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). * Between 10% and 30% of records had missing information and were excluded from the calculation of these estimates. 
The overall rate of operative vaginal delivery was very stable over this five‐year period, going from 14.7% (95% CI: 14.0–15.4) of women with a vaginal birth in 2005–2006, down to 13.3% (95% CI: 12.7–
13.9) in 2007–2008 and back up to 14.4% (95% CI: 13.8–15.0) in 2009–2010. 
Among those meeting the definition for standardized nulliparous women, the rates of operative vaginal delivery were on average approximately 71% higher than in the overall obstetrical population, and showed little change across the five fiscal years. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 66 Figure 4.12 Data source Definition of indicator Rate of cesarean delivery, by fiscal year South East and Champlain (SEC) LHIN Region, 2005‐2006 to 2009–2010 BORN Ontario (Niday Perinatal Database), 2005–2006 to 2009–2010 Local Health Integration Network (LHIN) 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 time). 
There rate of cesarean delivery in the South East and Champlain LHIN Region showed little change over the five fiscal years, going from 28.0% (95% CI: 27.3–28.7) in 2005–2006 to 28.9% (95% CI: 28.3–
29.6) in 2009–2010. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 67 Figure 4.13 Data source Definition of indicator Rate of cesarean delivery, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) 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 time). 
Across the South East and Champlain LHIN Region, the rate of cesarean delivery in 2009–2010 was 28.9%, similar to the provincial rate of 28.3%. 
The rate of cesarean was 28.1% in South East LHIN and 29.2% in Champlain LHIN. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 68 Figure 4.14 Data source Definition of indicator 

Rate of cesarean delivery, by hospital level of care South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) 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 time). The rate of cesarean showed some variation by the hospital level of care designation, with the highest rate of cesarean among women who gave birth in a Level II+ centre (36.7%). The rates among women who gave birth in Level I, II or III hospitals were similar (approximately 27%). Within each level of care designation, the rate of cesarean delivery fluctuated slightly over the five fiscal years between 2005–2006 and 2009–2010 within some levels of care and was very stable in others (Level I: 25.7% and 27.7%, respectively; Level II: 26.6% and 26.6%; Level II+: 33.2% and 36.7%; Level III: 27.4% and 27.3%) (data not shown in figure). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 69 Definition of indicator Data source TOTAL POPULATION 1,596 1,489 107 1,307 348 45 900 322 219 284 163 771 2,296 183 76 107 1,099 172 14 900 306 193 165 139 204 825 16,191 28.0 49.4 31.1 100.0 95.0 88.1 58.2 85.3 26.5 35.9 5.1 100.0 84.1 11.5 100.0 2.1 0.3 5.6 2.0 1.4 1.8 1.0 4.8 14.2 9.2 0.7 8.1 9.9 11.0 1.0 23.1 12.0 D Relative size of group (B*100/16,191) 21.9 28.0 (1.1) (0.1) (5.6) 1.9 1.2 1.0 0.9 1.3 5.1 4,910 185 13 1,057 308 238 209 222 239 975 92 81 1,255 173 1.1 (0.5) (0.7) 6.8 521 165 120 686 A # of cesarean deliveries 485 (3.5) (1.0) 0.8 4.5 E Contribution to overall rate (A*100/16,191) 3.5 16,968 408 43 1,057 321 262 342 266 937 1,910 1,573 81 1,508 1,654 1,797 165 4,329 1,962 3,477 B Total # of deliveries 28.9 45.3 30.2 100.0 96.0 90.8 61.1 83.5 25.5 51.0 5.8 100.0 83.2 10.5 29.0 100.0 2.8 35.0 100.0 2.4 0.3 6.2 1.9 1.5 2.0 1.6 5.5 11.3 9.3 0.5 8.9 9.7 10.6 1.0 25.5 11.6 D Relative size of group (B*100/16,968) 20.5 2009–2010 C Rate of cesarean (A*100/B) 13.9 28.9 (1.1) (0.1) (6.2) 1.8 1.4 1.2 1.3 1.4 5.7 (0.5) (0.5) 7.4 1.0 (3.1) (1.0) 0.7 4.0 E Contribution to overall rate (A*100/16,968) 2.9 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 70 BORN Ontario (Niday Perinatal Database), 2005–2006 and 2009–2010 Local Health Integration Network (LHIN) 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 time). For this analysis, rates of cesarean are calculated in each of 10 categories of the Robson classification system.30 Records with missing information on the component variables were included in a separate category. 4,535 1,785 159 3,741 562 159 127 31.5 100.0 3.4 37.1 1,944 3,548 C Rate of cesarean (A*100/B) 16.1 B Total # of deliveries A # of cesarean deliveries 573 721 2005–2006 Rate of cesarean delivery, by Robson classification groups South East and Champlain (SEC) LHIN Region, 2005–2006 and 2009–2010 Nulliparous, singleton, cephalic, ≥37 weeks, spontaneous labour 2 Nulliparous, singleton, cephalic, ≥37 weeks, induced labour or cesarean before labour (2a) Induced labour (2b) Cesarean before labour 3 Multiparous, singleton, cephalic, ≥37 weeks, no previous cesarean, spontaneous labour 4 Multiparous, singleton, cephalic, ≥37 weeks, no previous cesarean, induced labour or cesarean before labour (4a) Induced labour (4b) Cesarean before labour 5 Multiparous, singleton, cephalic, ≥37 weeks, previous cesarean (5a) Spontaneous labour (5b) Induced labour (5c) Cesarean before labour 6 Nulliparous, singleton, breech 7 Multiparous, singleton, breech 8 Multifetal pregnancy 9 Singleton, transverse or oblique lie 10 Singleton, cephalic, <37 weeks All others with missing information on presentation, parity, gestational age, type of labour or previous cesarean 1 Robson classification group Figure 4.15 
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 8.9% of the total obstetrical population (1,508/16,968), it had the largest absolute number of cesarean deliveries, accounting for 25.6% of all cesarean deliveries (1,255/4,910). The relative size of this group of the obstetric population showed little change between 2005–2006 and 2009–2010. 
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 11.6% of the obstetric population (1,962/16,968) and had the second largest absolute number of cesarean deliveries, which accounted for 14.0% (686/4,910) 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 (35.0% versus 13.9%, respectively). The relative size of Group 2 in the obstetric population showed little change between 2005–2006 and 2009–2010. 
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 20.5% of the obstetric population (3,477/16,968) and had the third largest absolute number of cesarean deliveries, which accounted for 9.9% (485/4,910) of all cesarean deliveries. 
Together, the contribution of the three groups presented above (Robson Groups 1, 2 and 5) accounted for about half (49.5%) of the overall rate of cesarean, 41.0% of the total obstetrical population and 49.4% of the total number of cesarean deliveries in 2009–2010. 
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 (46.0%). These two groups comprise a similar relative size; however the rate of cesarean in Group 1 (13.9%) is about four times higher than the rate in Group 3 (2.8%). This is reflected in the contribution to the overall rate of cesarean –– 2.9% 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: 61.1% to 96.0% in 2009–2010); however, collectively, they make a small (5.7%) contribution to the overall rate of cesarean. 
Between 2005–2006 and 2009–2010 in the SEC LHIN Region, there was no 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 slightly from 14.2% to 11.3%; however, there was a small increase in the contribution of this group to the overall rate of cesarean from 5.1% to 5.7%. In particular in this region, there are several hospitals with incomplete data capture on fetal presentation, especially for cesarean deliveries. This is a very important data quality issue that affects the utility of the Robson classification, since the accuracy of the rates, relative sizes and contribution of each group to the overall cesarean rate is adversely impacted by missing information. *not including the contribution of records with missing information BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 71 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 72 Figure 4.16 Data source Definition of indicator 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 South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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 South East and Champlain LHIN Region in 2009–2010, the proportion of elective repeat cesarean deliveries at term gestation that were performed prior to 39 weeks was 52.6% (4.5% at 37 weeks and 48.1% at 38 weeks). A further 41.8% were performed at 39 weeks. 
Across Ontario, 57.6% of elective repeat cesarean deliveries at term were performed before 39 weeks’ gestation. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 73 Figure 4.17 Data source Definition of indicator Rate of episiotomy or 3rd/4th degree perineal laceration, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital 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). 
In 2009–2010, the rate of episiotomy was 9.4% in South East LHIN and 11.2% in Champlain LHIN. The rate of episiotomy across the SEC LHIN Region (10.8%) was considerably lower 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 3.8% in the SEC LHIN Region. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 74 Figure 4.18 Rate of episiotomy or 3rd/4th degree perineal laceration, by fiscal year South East and Champlain (SEC) 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 The number of women with an episiotomy or a 3rd or 4th degree perineal laceration, expressed as a indicator 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 was 13.5% (95% CI: 12.8–14.2) in 2005–2006, gradually decreasing to 10.5% (95% CI: 9.9–11.0) in 2008–2009. In 2009–2010, the rate of episiotomy was 10.8% (95% CI: 10.2–11.3). 
The rate of 3rd or 4th degree perineal laceration was very stable across the five fiscal years. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 75 Figure 4.19 Proportion of women with intrapartum complications, by fiscal year South East and Champlain (SEC) 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 The number of women with one or more intrapartum complications, expressed as a percentage of the indicator 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. A complete list of the intrapartum complication categories collected by the database can be found in APPENDIX G. 
In 2009–2010, the most common intrapartum complications were non‐reassuring fetal status (14.5%), meconium (11.8%), non‐progressive labour/lack of descent/dystocia (8.4%) and other (8.1%). 
The proportion of women with one or more intrapartum complications increased from 30.9% (95% CI: 30.1–31.7) in 2006–2007 to 37.9% (95% CI: 37.1–38.6) in 2009–2010. 
In 2006–2007, 2007–2008 and 2008–2009, the proportion of records missing this information was 20.0%, 13.4% and 14.0%, 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 intrapartum complications since the data capture was more complete than in the earlier years. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 76 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 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 77 Figure 4.20 Data source Definition of indicator Notes: Rates of pharmacologic pain management among women who had a vaginal live birth, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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). 1. Women may have received more than one type of pain management; therefore, the rates in this figure are not mutually exclusive. 
Across the South East and Champlain LHIN Region, 60.4% of women 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 was 55.1% in South East LHIN and 62.2% in Champlain LHIN. Across the province, 62.5% of women used regional anesthesia. 
About 36% (35.7%) of women in the SEC Region used another form of analgesia for pain management, including narcotics, nitrous oxide and pudendal –– considerably higher than the background provincial estimate of 19.8%. The proportion of women with a vaginal live birth who used another form of analgesia was much higher in South East LHIN (50.7%) than in Champlain LHIN (30.7%). 
Six percent (6.1%) of women with a vaginal live birth did not use any method of pharmacological pain management (data not shown in figure). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 78 Figure 4.21 Rates of pharmacologic pain management among women who had a vaginal live birth, by fiscal year South East and Champlain (SEC) 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 The number of women who had regional anesthesia (epidural, spinal‐epidural combination, spinal) or indicator 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). * Between 10% and 30% of records had missing information and were excluded from the calculation of these estimates. Notes: 1.
Women may have received more than one type of pain management; therefore, the rates in this figure are not mutually exclusive. 
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 was very stable over the five fiscal years –– 59.0% (95% CI: 58.0–60.0) in 2005–2006 and 60.4% (95% CI: 59.6–61.3) 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 increased slightly from 33.6% (95% CI: 32.6–34.5) to 35.7% (95% CI: 34.8–36.5). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 79 Figure 4.22 Data source Definition of indicator Notes: Rates of pharmacologic pain management among women who had a vaginal live birth, by hospital level of care South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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). 1. Women may have received more than one type of pain management; therefore, the rates in this figure are not mutually exclusive. 
The proportion of women who had a vaginal live birth and received regional anesthesia for pain management during labour or birth was lowest in Level I hospital sites (43.5%) and highest in the Level II+ hospital site (70.5%). 
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 (52.6%) and Lowest in Level II hospitals (17.1%). 
Level II hospitals had the highest proportion of women with a vaginal live birth who did not use any pharmacological pain management (9.4% – data not shown in figure). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 80 Figure 4.23 Data source Definition of indicator Notes: Rates of pharmacologic pain management among women who had a cesarean live birth, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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). 1. Women may have received more than one type of pain management; therefore, the rates in this figure are not mutually exclusive. 
Among women who had a live birth delivered by cesarean, the most commonly used form of pain management was spinal (53.5%), followed by epidural (31.9%). 
The proportion of women who received a general anesthetic was 4.1% in the SEC LHIN Region in 2009–2010, corresponding to an absolute number of 189 women. Among these women, the majority (149 women, or 78.9%) had an unplanned cesarean delivery. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 81 Figure 4.24 Rates of pharmacologic pain management among women who had a cesarean live birth, by fiscal year South East and Champlain (SEC) 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 The number of women who had epidural, spinal, spinal‐epidural combination or general anesthesia for indicator 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). * Between 10% and 30% of records had missing information and were excluded from the calculation of these estimates. Notes: 1.
Women may have received more than one type of pain management; therefore, the rates in this figure are not mutually exclusive. 
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 was stable over this time period (31.6%, 95% CI: 30.2–33.1 in 2005–2006 and 31.9%, 95% CI: 30.5–33.3 in 2009–2010), while the proportion who received spinal decreased from 63.9% (95% CI: 62.4–65.4) to 53.5% (95% CI: 52.0–54.9). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 82 Figure 4.25 Rates of pharmacologic pain management among women who had a cesarean live birth, by hospital level of care South East and Champlain (SEC) LHIN Region, 2009–2010 *
Data source BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth Definition of The number of women who had epidural, spinal, spinal‐epidural combination or general anesthesia for indicator 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). * Between 10% and 30% of records had missing information and were excluded from the calculation of these estimates. Notes: 1.
Women may have received more than one type of pain management; therefore, the rates in this figure are not mutually exclusive. 
The proportion of women who received a general anesthetic for their cesarean delivery was highest in Level III hospitals (6.8%). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 83 Figure 4.26 Data source Definition of indicator Length of second stage of labour among women with a vaginal birth, by parity South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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 overall was 103 minutes among nulliparous women (i.e., parity = 0) and 39 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 84 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 Data source Fetal mortality rate ≥500 grams, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth Definition of indicator 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 SEC Region, the rate of stillbirth ≥500 g in 2009–2010 was 3.88 per 1,000 total births. The rate of stillbirth ≥500 g per 1,000 was 4.8 (95% CI: 3.0–7.5) in South East LHIN and 3.6 (95% CI: 2.6–4.8) in Champlain LHIN. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 85 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 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 86 Figure 4.28 Data source Definition of indicator Rate of preterm birth, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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 South East and Champlain LHIN Region in 2009–2010 was 9.5%, slightly higher than the rate for Ontario as a whole (8.2%). The majority of preterm births were between 34 and 36 weeks of gestational age at birth. 
There was little variability in the rate of preterm birth across the SEC LHIN Region (9.2% in South East LHIN and 9.5% in Champlain LHIN). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 87 Figure 4.29 Data source Definition of indicator 
Rate of preterm birth, by fiscal year South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 BORN Ontario (Niday Perinatal Database), 2005–2006 to 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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 increased slightly in the SEC LHIN Region between 2005–2006 and 2009–
2010. In 2009–2010, the rate of preterm birth was 9.5% (95% CI: 9.0–9.9). The corresponding number of babies born at <37 weeks of gestational age was 1,630. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 88 Figure 4.30 Data source Definition of indicator Rate of preterm birth, by hospital level of care South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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 fluctuated from a low of 4.6% in Level II hospitals to a high of 15.8% in the Level II+ hospital. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 89 Figure 4.31 Data source Definition of indicator 

Rate of preterm birth, by plurality and fiscal year South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 BORN Ontario (Niday Perinatal Database), 2005–2006 to 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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 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 slightly from 59.6% (95% CI: 55.5–63.7) in 2005–2006 to 63.7% (95% CI: 60.0–67.3) in 2009–2010. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 90 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 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 91 Figure 4.32 Data source Definition of indicator 
Rate of small for gestational age (SGA), by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth The number of singleton live births with a birth weight below the 10th percentile of the sex‐specific birth 62
weight distribution for gestational age 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 3rd percentile cut‐off. The rate of SGA (based on the 10th percentile) infants born in 2009–2010 in the South East and Champlain LHIN Region was 7.3%, slightly lower than the rate for Ontario (9.0%). This rate was very similar for both LHINs in the SEC Region. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 92 Figure 4.33 Data source Definition of indicator 
Rate of large for gestational age (LGA), by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth The number of singleton live births with a birth weight above the 90th percentile of the sex‐specific birth 62
weight distribution for gestational age, 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 South East and Champlain LHIN Region was 12.1%, slightly higher than the rate for Ontario (10.4%). This rate was very similar in both LHINs for the SEC Region. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 93 Figure 4.34 Data source Definition of indicator 
Rate of small for gestational age (SGA) and large for gestational age (LGA), by fiscal year South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 BORN Ontario (Niday Perinatal Database), 2005–2006 to 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth th
th
The number of singleton live births with a birth weight below the 10 percentile (SGA) or above the 90 62
percentile (LGA) of the sex‐specific birth weight distribution for gestational age, 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 South East and Champlain LHIN Region between 2005–2006 and 2009–2010. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 94 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 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 95 Figure 4.35 Data source Definition of indicator Rate of multiple birth, by fiscal year South East and Champlain (SEC) LHIN Region, 2005‐2006 to 2009–2010 BORN Ontario (Niday Perinatal Database), 2005–2006 to 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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 South East and Champlain LHIN Region in 2009–2010 was 4.0% (95% CI: 3.7–4.3), a slight increase compared with 2005–2006 (3.5%, 95% CI: 3.2–3.8, relative increase of 14%). 
The corresponding number of babies born in the region following a multiple gestation pregnancy increased from 578 in 2005–2006 to 699 in 2009–2010. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 96 Figure 4.36 Rate of multiple birth, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 Data source Definition of indicator BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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 both South East and Champlain LHINs. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 97 References 1.
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51. 65. Joss‐Moore LA, Lane RH. The developmental origins of adult disease. Curr Opin Obstet Gynecol 2009;21:230–4. 66. Lindsay J, Guyon G, Smylie J. Large‐for‐gestational‐age rate. In: Canadian Perinatal Health Report, 2008 Edition. Public Health Agency of Canada. Ottawa, 2008. p. 133–5. 67. Bjørstad AR, Irgens‐Hansen K, Daltveit AK, Irgens LM. Macrosomia: mode of delivery and pregnancy outcome. Acta Obstet Gynecol Scand 2010;89(5):664–9. 68. Raio L, Ghezzi F, Di Naro E, et al. Perinatal outcome of fetuses with a birth weight greater than 4500 g: an analysis of 3356 cases. Eur J Obstet Gynecol Reprod Biol 2003;109(2):160–5. 69. Lee YM, Cleary‐Goldman J, D'Alton ME. The impact of multiple gestations in late preterm (near‐term) births. Clin Perinatol 2006;33(4):777–92. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 100 70. Enkin M, Keirse M, Neilson J, Crowther C, Duley L, Hodnett E. A guide to effective care in pregnancy and childbirth. 3rd ed. Oxford: Oxford University Press; 2000. 71. Rand L, Eddleman KA, Stone J. Long‐term outcomes in multiple gestations. Clin Perinatol 2005;32(2):495–513. 72. Léon JA, Ohlsson A. Multiple birth rate. In: Canadian Perinatal Health Report, 2008 Edition. Public Health Agency of Canada. Ottawa, 2008. p. 155–7. 73. Martin JA, Park MM. Trends in twins and triplet births: 1980‐1997. Natl Vital Stat Rep 1999;47(24):1–16. 74. Alexander GR, Wingate MS, Salihu H, Kirby RS. Fetal and neonatal mortality risks of multiple births. Obstet Gynecol Clin N Am 2005;32(1):1–16. 75. Dodd J, Crowther C. Multiple pregnancy reduction of triplet and higher‐order multiple pregnancies to twins. Fertil Steril 2004;81(5):1420–2. 76. Dare MR, Crowther CA, Dodd JM, Norman RJ. Single or multiple embryo transfer following in vitro fertilisation for improved neonatal outcome: a systematic review of the literature. Aust N Z J Obstet Gynecol 2004;44(4):283–91. 77. Henderson J, Hockley C, Petrou S, Goldacre M, Davidson L. Economic implications of multiple births: inpatient hospital costs in the first 5 years of life. Arch Dis Child Fetal Neonatal Ed 2004;89:F542–5. doi:10.1136/adc.2003.043851. 78. Verberg MF, Macklon MS, Heijnen EM, Fauser BC. ART: Iatrogenic multiple pregnancy? Best Pract Res Clin Obstet Gynaecol 2007;21:129–43. doi:10.1016/j.bpobgyn.2006.09.011. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 101 C
HAPTER 5 POSTPARTUM AND NEWBORN
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 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 102 Figure 5.1 Proportion of live births with a 5‐minute Apgar score below 4 or between 4 and 6, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 Data source Definition of indicator BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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 0.4% in the South East and Champlain Region in 2009–2010, corresponding to a total of 64 live born infants. The majority of these 64 infants were born before 37 weeks of gestational age (61%). 
The proportion of neonates with a 5‐minute Apgar score between 4 and 6 was 1.7%, with more than two‐thirds of these infants born at 37 weeks of gestational age or higher (203/291). 
The proportion of neonates with a 5‐minute Apgar score less than 7 for the South East and Champlain Region as a whole was 2.1%, higher than the proportion for the province as a whole (1.4%). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 103 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 South East and Champlain (SEC) LHIN Region, 2009–2010 *
Data source Definition of indicator BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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). * Between 10% and 30% of records had missing information and were excluded from the calculation of these estimates. 
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, 3.6% of live births (corresponding to 179 infants) in Level III centres had a 5‐minute Apgar score less than 7. 
The proportion of infants with a 5‐minute Apgar score less than 7 was very similar in Level I (1.4%), Level II (1.7%) and Level II+ (1.6%) centres. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 104 Figure 5.3 Proportion of live births requiring resuscitation, by gestational age South East and Champlain (SEC) LHIN Region, 2009–2010 [Data not presented] Data source Definition of indicator 

BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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 South East and Champlain LHIN Region in 2009–2010, 12.0% 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 hospitals, the proportion of records with missing information exceeded 30%. Since preterm infants are more likely to require resuscitation, this indicator will not provide a reliable estimate of newborn resuscitation in the region 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 South East and Champlain (SEC) LHIN Region, 2009–2010 [Data not presented] Data source Definition of indicator BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth 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 South East and Champlain LHIN Region, 12.0% of records were missing information related to newborn resuscitation, and 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 region and is therefore not presented. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 105 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). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 106 Figure 5.5 Rate of exclusive breastfeeding at discharge among term live births, by LHIN of birth South East and Champlain (SEC) LHIN Region, 2009–2010 §
Data source BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth Definition of The number of infants who were exclusively breastfed at the time of discharge from hospital, expressed indicator 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 11.2% of term live births for Ontario (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., 30
not transferred to NICU or special care nursery). 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. 
In 2009–2010, the rate of exclusive breastfeeding at the time of discharge from hospital was 56.4% in South East and 64.9% in Champlain. 
Rates of supplementation (i.e., the baby received a combination of breast milk and formula) was 23.5% in South East and 21.6% in Champlain (data not shown in figure). BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 107 References 1.
Annibale DJ, Bissinger RL. The golden hour. Adv Neonatal Care 2010;10(5):221–3. 2.
Apgar V. The newborn (Apgar) scoring system: reflections and advice. Pediatr Clin North Am 1966;13:645–50. 3.
Apgar VA. A proposal for a new method of evaluation of the newborn infant. Anesth Analg 1953;32:260–7. 4.
Casey BM, McIntire DD, Leveno KJ. The continuing value of the Apgar score for the assessment of newborn infants. NEJM 2001;344:467–71. 5.
Martin GI, Hankins GD, American Academy of Pediatrics Committee on Fetus and Newborn 2005–2006. The Apgar Score. Pediatrics 2006;117:1444–7. 6.
Nelson KB, Ellenberg JH. Apgar scores as predictors of chronic neurologic disability. Pediatrics 1981;68:36–44. 7.
American College of Obstetricians and Gynecologists’ Task Force on Neonatal Encephalopathy and Cerebral Palsy, American College of Obstetricians and Gynecologists, American Academy of Pediatrics. Neonatal encephalopathy and cerebral palsy: Defining the pathogenesis and pathophysiology. Washington: American College of Obstetricians and Gynecologists, 2003. 8.
Freeman JM, Nelson KB. Intrapartum asphyxia and cerebral palsy. Pediatrics 1988;82:240–9. 9.
Saugstad OD. Practical aspects of resuscitating newborn infants. Eur J Pediatr 1998;157;S11–5. 10. Tan A, Schulze AA, O'Donnell CP, Davis PG. Air versus oxygen for resuscitation of infants at birth. Cochrane Database Syst Rev 2005;18(2):CD002273. 11. Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, Gallagher J, et al.; American Heart Association. Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2010;126(5):e1400–13. DOI: 10.1542/peds.2010‐2972E. 12. Baskett TF, Allen VM, O'Connell CM, Allen AC. Predictors of respiratory depression at birth in the term infant. Br J Obstet Gynecol 2006;113:769–74. 13. Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro S, et al. Promotion of breastfeeding intervention trial (PROBIT): A randomized trial in the Republic of Belarus. JAMA 2001;285(4):413–20. 14. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev 2002;1. Art. No.: CD003517. 15. Lucas A, Morley R, Cole RJ, Lister G, Leeson‐Payne C. Breast milk and subsequent intelligence quotient in children born preterm. Lancet 1992;339(8788):261–4. 16. Anderson JW, Johnstone BM, Remley DT. Breastfeeding and cognitive development: A meta‐analysis. Am J Clin Nutr 1999;70:525–35. 17. Howie PW. Protective effect of breastfeeding against infection in the first and second six months of life. Adv Exp Med Biol 2002;503:141–7. 18. Raisler J, Alexander C, O'Campo P. Breastfeeding and infant illness: A dose‐response relationship? Am J Public Health 1999;89:25–30. 19. Rea MF. Benefits of breastfeeding and women's health. J Pediatr (Rio J) 2004;80(5 Suppl):S142–6. 20. Labbock MH. Health sequelae of breastfeeding for the mother. Clin Perinatol 1999;26:491–503. 21. Health Canada. Exclusive Breastfeeding Duration. 2004 Health Canada Recommendation [Internet]. Health Canada. Ottawa, 2004 [cited 02 Dec 2009]. Available from: http://www.hc‐sc.gc.ca/fn‐an/alt_formats/hpfb‐
dgpsa/pdf/nutrition/excl_bf_dur‐dur_am_excl‐eng.pdf. 22. Canadian Paediatric Society. Exclusive breastfeeding should continue to six months. Paediatr Child Health 2008;10(3):148. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 108 23. Canadian Paediatric Society, Dietitians of Canada and Health Canada. Nutrition for Healthy Term Infants [Internet]. Minister of Public Works and Government Services, Ottawa, 2005 [cited 27 Nov 2009]. Available from: http://www.hc‐sc.gc.ca/fn‐an/pubs/infant‐nourrisson/nut_infant_nourrisson_term‐eng.php. 24. Chalmers B, Royle C. Breastfeeding rates. In: What Mothers Say: The Canadian Maternity Experiences Survey. Public Health Agency of Canada. Ottawa, 2009. p. 173–8. 25. World Health Organization. Global Strategy for infant and young child feeding. Geneva: WHO; 2003. 26. World Health Organization. Protecting, promoting and supporting breast‐feeding: The special role of maternity services ‐ A Joint WHO/UNICEF Statement. Geneva: WHO; 1989. 27. Caldeira AP, Goncalves E. Assessment of the impact of implementing the Baby‐Friendly Hospital Initiative. J Pediatr (Rio J) 2007;83(2):127–32. 28. Merten S, Dratva J, Ackermann‐Liebrich U. Do baby‐friendly hospitals influence breastfeeding duration on a national level? Pediatrics 2005;116(5):702–8. 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 109 CHAPTER 6 MATERNAL AND NEWBORN SCREENING
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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 110 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 South East and Champlain (SEC) LHIN Region, 2009–2010 Data source Definition of indicator Notes: 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). 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 62.4% across the region, with a lower screening ratio in South East than Champlain. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 111 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 South East and Champlain (SEC) LHIN Region, 2009–2010 *
*
Data source BORN Ontario (Niday Perinatal Database), 2009–2010 Local Health Integration Network (LHIN) based on hospital of birth Definition of The number of women who had Group B Streptococcus screening completed, expressed as a percentage indicator of the total number of women who delivered at ≥37 weeks of gestation (in a given place and time). * Between 10% and 30% of records had missing information and were excluded from the calculation of these estimates. 
Among women who delivered at or after 37 weeks of gestation, the proportion screened for Group B Streptococcus during pregnancy was high across the South East and Champlain LHIN Region. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 112 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 South East and Champlain (SEC) LHIN Region, 2009–2010 LHIN of residence Number of Number with Proportion of infants with a positive infants with a newborn screen positive screening screen completed LHIN 10 – South East LHIN 11 – Champlain SEC LHIN REGION ONTARIO Data source Definition of indicator Notes: 4,425 12,869 17,294 142,990 34
130
164
1,312 0.77
1.01
0.95
0.92 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). 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 South East and Champlain LHIN Region with a positive screen on newborn screening was 0.95% 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 113 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 South East and Champlain (SEC) LHIN Region, 2009–2010 Data source Definition of indicator Notes: 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). 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 84.8% in South East and 91.9% in Champlain. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 114 Figure 6.5 Proportion of infants who received a Parkyn screen score of nine or greater, by LHIN of residence South East and Champlain (SEC) LHIN Region, 2009–2010 Data source Definition of indicator 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, the proportion of infants who were screened using the Parkyn Tool and received a score of nine or greater (indicating high risk) was 28.4% (1,074/3,784) in South East and 20.7% (2,446/11,793) in Champlain. 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%. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 115 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 116 APPENDIX A BORN Ontario Contact Information BORN Ontario Scientific Office Mark Walker, Scientific Director Tel: (613) 737‐8899 ext 76655 Email: mwalker@ohri.ca Ann Sprague, Scientific Manager Tel: (613) 737‐8579 Email: asprague@ottawahospital.on.ca Deshayne Fell, Epidemiologist Tel: (613) 737‐8899 ext 73933 Email: dfell@ohri.ca BORN Ontario Coordinators Barbara Chapman, Quality Management Specialist Tel: (905) 580‐1637 Email: bchapman@BORNOntario.ca Erie St. Clair and South West LHINs Monica Poole Tel: (226) 268‐2819 Email: mpoole@bornontario.ca Waterloo Wellington and Hamilton, Niagara, Haldimand, Brant LHINs Kelly Pearce Tel: (905) 521‐2100 ext 73827 Email: kpearce@HHSC.CA Greater Toronto Area Vivian Holmberg Tel: (416) 305‐7726 Email: vholmberg@bornontario.ca Tammy Budhwa Tel: (289) 218‐8248 Email: tbudhwa@bornontario.ca Connie Bartley Tel: (416) 586‐4800 ext 7449 Email: cbartley@mtsinai.on.ca South East and Champlain LHINs Cathy Ottenenhof Tel: (613) 549‐6666 ext 4622 Email: ottenhoc@kgh.kari.net North Simcoe Muskoka, North East and North West LHINs Glenda Hicks Tel: (705) 523‐7100 ext 3320 Email: ghicks@hrsrh.on.ca BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 117 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 (asprague@ottawahospital.on.ca) for data application requests, including further breakdown of the data tables provided in this report. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 118 APPENDIX C Number of total hospital births, by hospital site and fiscal year South East and Champlain (SEC) LHIN Region, 2005–2006 to 2009–2010 Fiscal Year LHIN South East Hospital 2005–06 2006–07 2007–08 2008–09 2009–10 n n n n n 1,391 1,410 1,472 1,504 1,419 61 52 42 54 38 292 221 266 240 253 Brockville General Hospital 332 324 370 385 388 Kingston General Hospital 2,098 2,181 2,137 2,143 2,054 405 394 396 399 500 511 569 616 596 596 237 234 264 244 242 471 392 547 561 629 Renfrew Victoria Hospital 110 123 104 104 105 Almonte General Hospital 234 319 277 306 347 Hôpital Montfort 1,523 1,440 1,666 1,878 1,968 Ottawa Hospital ‐ Civic Campus 3,524 3,530 3,445 3,294 3,204 Ottawa Hospital ‐ General Campus 2,911 3,044 2,882 2,890 3,004 Queensway Carleton Hospital 2,406 2,543 2,313 2,694 2,604 Quinte Health Care ‐ Belleville General Hospital Quinte Health Care – Prince Edward County Memorial Hospital Perth and Smith Falls District Hospital ‐ Smiths Falls Winchester District Memorial Hospital Cornwall Community Hospital ‐ McConnell Site Hopital General de Hawkesbury and District General Hospital Hopital Regional de Pembroke Regional Hospital Champlain Data source Definition of indicator Notes: BORN Ontario (Niday Perinatal Database), 2005–2006 to 2009–2010 The number of total births (live births and stillbirths) to Ontario women in a hospital in the South East and Champlain (SEC) LHIN Region in 2005–2006 to 2009–2010. 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 119 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 120 APPENDIX E Obstetrical complication categories in BORN–Niday Perinatal Database* Field Name Data Entry Options Instructions / Definitions Obstetrical complications Pick‐list – Select one or more (default):  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 BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 121 Field Name Data Entry Options Instructions / Definitions 
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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) * 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 122 APPENDIX F Hospital sites and level of care South East and Champlain (SEC) LHIN Region LHIN South East Hospital Level of Care Quinte Health Care ‐ Belleville General Hospital I Quinte Health Care – Prince Edward County Memorial Hospital I Perth and Smith Falls District Hospital ‐ Smiths Falls I Brockville General Hospital I Kingston General Hospital III Winchester District Memorial Hospital I Cornwall Community Hospital ‐ McConnell Site I Hôpital General de Hawkesbury and District General Hospital I Hôpital Regional de Pembroke Regional Hospital I Renfrew Victoria Hospital I Almonte General Hospital I Hôpital Montfort II Ottawa Hospital ‐ Civic Campus II+ Ottawa Hospital ‐ General Campus III Queensway Carleton Hospital II Champlain BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 123 APPENDIX G Intrapartum complication categories in BORN–Niday Perinatal Database* Field Name Data Entry Options Instructions / Definitions Intrapartum complications Pick‐list – Select one or more (default):  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. * 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. BORN Ontario Perinatal Health Report 2009–2010 – South East and Champlain (SEC) LHIN Region 124 1765 Alta Vista Dr. Suite 106 Ottawa, ON K1G 3Y6 P: 613‐523‐3781 F: 613‐523‐9057 www.BORNOntario.ca info@BORNOntario.ca