Maternity care in Norway Bjørn Backe Professor MD PhD NTNU

Maternity care in Norway
Bjørn Backe
Professor MD PhD
NTNU
and
National Advisory
Committee for
Obstetrics
1
Parliament decisions on delivery units
- changes in organizing obstetric
care in Norway
Pål Øian
Department of Obstetrics and Gynaecology
University of Tromsø
2
Contents:
History & recent development:
1.
2.
3.
Midwifery in Norway
Antenatal care
Obstetrical care
–
–
–
3
Differentiated
Decentralized
Continuity of care (same care provider throughout)
4
Midwifery in Norway (I)
•
•
•
•
1814: 54 midwives in Norway (+ a few Danish)
1818: School of Midwifery in Kristiania (Oslo)
1861: School of Midwifery in Bergen
1889: Midwifery Law
– District midwives
– Public employed
– Monopoly
– Mandatory to use midwife services
• No of District midwives, 1950: 1400, 1970: 250
5
Midwifery in Norway (II)
• Up to 1940 Home delivery was the rule
– (1950: 25 % home deliveries)
• From ~1940 – obstetrical care institutionalized
– Hospital deliveries in local hospitals
– Rural maternity units (Fødestuer – ”cottage hospitals”)
• Community, charity organisations etc.
• Staffed by District Midwives
• 1990 District midwife system was terminated
– From 1990: Community midwives
6
Midwives and doctors in Norway 1900-2000
16000
14000
12000
10000
Midw
Doct
8000
6000
4000
2000
0
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
7
(Source: Statistics Norway)
Norwegian midwives are
• (Usually) Public employed
– Communities or
– (public) hospital owners
• Autonomous profession
– Midwives (and nurses) are not doctors’ assistants
• Manage normal vaginal deliveries
– Authorized to handle deliveries and
– Authorized to decide when they need help
8
Antenatal Care in Norway
9
Short History of ANC in Norway (I)
• Frequent urine testing in pregnancy for protein
recommended in articles (1904) and text books (1913)
• Organized care introduced 1938 as part of community based
primary health care
– Stortinget 1934 voted for a Swedish/Danish/Finnish system,
the administration did not comply because of the costs
– Medical association (pediatricians) intervened 1938 and GPs was
involved
• 1947: Syphilis testing of pregnant women mandatory
– ANC became ”mandatory”
10
Short history of ANC in Norway (II)
• ANC was provided by the GPs and District Midwives were
usually not involved in ANC
• 1976: Stortinget stated that ANC should be provided by
midwives (nothing happened)
• ~1984: Public debate about quality of ANC/ higher stillborn
rates in N than in S and Dk
11
Perinatal mortality in Denmark, Finland, Norway and
Sweden 1951-1979
(Larssen KE, Bakketeig LS,
Bergsjø P, Finne PH:
Perinatal service in
Norway during the
1970s.
12
NIS report 6/81)
Perinatal audit 1980 – 30 % avoidable
deaths
13
Quality problem in perinatal care –
Official report 1984, remedial actions:
•
•
•
•
•
•
•
•
14
Routine audit of deaths
Guidelines for ANC
Midwives should be involved in ANC
Guidelines for equipment and
transfer of newborns
Plans for education
and post graduate education
Etc.
Midwives in ANC – slow process
• 1984: Official report recommended that midwives should do
ANC
• 1990: Community health care act midwife recommendation
• 1995: Community health care act instructed communities to
provide midwife services
• 2000: Midwives provide ~50 % of ANC visits (Backe 2002)
– Midwives in all communities (~450)
15
New guidelines for ANC (2005)
•
•
•
•
•
•
16
Evidence based
Fewer controls
Less medicalization?
Less rituals
Midwives or GPs
Continuity of care advocated
17
Obstetrical care in Norway
• Has always been Decentralized
• And Always Midwife Based
• But No continuity of care
– ANC provided by GP
– Midwives delivered and provided care after delivery
– Community health nurses followed up
18
Obstetrical units by number of births
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
No of births
Danmark
Sweden
Norway
1
2
3
No of institutions
19
4
5
Distribution of Births in the Nordic Countries by
Size of Obstetric Unit
Norway
(n=61.307)
Sweden
(n=88.837)
Finland
(n=59.567)
Denmark
(n=62.262)
Total no of institutions
62
52
44
50
No of units with < 500
deliveries per year
30
7
12
9
11.1 %
2.4 %
6.4 %
3.7 %
% of deliveries in
units with < 500
20
deliveries per year
Problems with maternity services in
rural areas:
• Debate on quality of care in small obstetrical units
• Recruitment problems in small units
• Problems caused by temporary staff
• “Centralization! Like Sweden!”
– Births are unpredictable
– Units are too small
– Surgeons leave obstetrics
Standard textbook 2004
21
“Professional requirements for birth institutions.”
Norwegian Directorate of Health 1997
•
Level 1 – Maternity homes (Midwives, selected low risk)
– At least 40 deliveries per year
•
Level 2 – Obstetrical departments (+ OBGYN & anesthesiologists,
pediatrician available)
– At least 4-500 deliveries per year
•
22
Level 3 – “Kvinneklinikk” - at least 1.500 deliveries per year (+
NICU)
Lofoten project 1997-98
•
Small obstetric department
reorganized as midwife-based
obstetric unit
•
Heavy protests from
– Public
– Doctors
– Midwives
23
Lofot-project 1997-1998
* “Uptake rate” reduced from 90 % to 70 %
* No perinatal deaths attributable to the reorganization
* Obstetrician/surgeon on call contacted 30 (1997) and 38
(1998) times annually
* 29 women transferred during labor (6 %)
* No transport deliveries during transfer
* CS rate 4.3 % and 1.8 %
* CS rate in the population reduced from 15.8 % to 11.8 %
Vold IN, Holt J, Johansen MV, Backe B, Øian P. Modifisert fødestuedrift - et alternativ for små fødeavdelinger? Tidsskr Nor
Lægeforen 2001; 121: 941-5.
24
Holt J, Vold IN, Backe B, Johansen MV, Øian P. Child births in a modified midwife managed unit: Selection and transfer according
to intended place of delivery. Acta Obstet Gynecol Scand 2001, 80: 206-12
Lay-women conference 1999
Conference on obstetrics in rural areas 2000
•
•
•
•
25
Decentralised
Continuity of care
Midwives involved in ANC
Obstetrical care differentiated according to risk
Health Directorate and
National Research Council
Parliament resolutions (2001)
26
•
Obsterical Care must be Decentralized
•
And Differentiated According to Risk
•
The Professional requirements (1997) must be followed
•
A National Advisory Committee for Obstetrics should be appointed
to assist hospital owners in the reorganization of obstetrical
services
Obstetrical institutions, Norway 1974-2005
1974
1980
1990
1999
2005
Cottage hospital
59
30
18
9
10
Maternity home
2
1
Dept of obst
(surgeon)
39
33
7
1
Dept of obst
(gyn)
31
33
46
45
42
2
5
57
57
Midwife obst
unit in local
hospital
Sum
27
131
97
71
Parliament resolutions: Implications
• Small obstetrical departments (< 400 deliveries per year)
must be converted to maternity homes
– about 50 % of obstetrical units in Norway!
• All obstetrical departments must distinguish between
normal pregnant women and high-risk patients
– ABC units
– Green and red women
28
Births in Region North
•
•
•
•
•
29
18 birth institutions:
3 hospitals
9 hospitals
6 cottage hospitals
During transport:
Total 6.000 deliveries
> 400 deliveries
< 400 deliveries
550 deliveries
40 deliveries
National advisory Committee for
Obstetrics
•
•
•
•
•
•
•
•
30
Stine Bernitz
Nina Schmidt
Atle Klovning
Torunn Eikeland
Bjørn Backe
Steinar Pleym Pedersen
Pål Øian
Sølvi Taraldsen
Midwife, Fredrikstad
Midwife, Alta
General practitioneer, Bergen
OBGYN, Haugesund
OBGYN, Trondheim
Hospital director, Lofoten
OBGYN (head), Tromsø
OBGYN (secretary), Directorate
for Health and Social affairs,
Oslo
Parliament resolution of 2001 is a crossroad
• A revolution is taking place in Norwegian obstetrics
• The Parliament decisions are fair and evidence-based
• We are moving in the direction recommended by WHO (Safe
Motherhood 1996)
31
“So where then should a woman give birth?”
“.. in a place she feels is safe ... For a low-risk pregnant woman,
this can be at home, at a small maternity clinic or birth
centre in town or perhaps at the maternity unit of a larger
hospital.”
(WHO Safe Motherhood 1996, p 12)
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