Head first: birth centres in Ontario

Ontario recently announced funding for two birth centres that will be led by midwives.

The government has indicated it is opening birth centres partly to move care out of hospitals and save money.

Although birth centres are probably safe and may improve maternity care, it is less clear whether Ontario’s birth centres will indeed reduce costs.

The Ontario government recently announced that it will provide funding for two birth centres in the province. Many news reports, as well as the Association of Ontario Midwives, have claimed that the birth centres have the potential to decrease costs. But with no details about how the birth centres will operate, that claim requires further exploration.

A third option

Obstetricians, midwives and family doctors all provide maternity care in Ontario. While obstetricians deliver the vast majority of babies – around 90% – a substantial proportion of women would prefer a midwife. In Ontario, midwives currently deliver babies both at home and in hospitals, but birth centres are a third option.

In many countries, a substantial proportion of women deliver their babies in birth centres. Unlike the birth centres that have been proposed in Ontario, however, many of these are directly attached to a hospital labour and delivery ward, and staffed by both midwives and obstetricians. Closer to home, Quebec introduced freestanding midwife-led birth centres in the mid-1990s, and there is at least one freestanding birth centre in Western Canada.

The hope is that freestanding birth centres will provide a better experience for mothers than hospitals, while also providing equivalent or better quality care. In particular, midwife care may increase the chances of a woman having a vaginal birth with minimal medical intervention. If complications occur, women are rapidly transferred to a hospital where obstetricians are available to perform Caesarean sections.

The Ontario Medical Association responded to the government’s announcement by expressing concern that freestanding birth centres “may fragment or silo the delivery of maternity care in Ontario.” William Mundle, the chair of the obstetrics and gynecology section of the Ontario Medical Association also noted that “minutes can mean the difference between life and death” and that even women with low-risk pregnancies may need rapid access to surgeons and hospitals.

The evidence for birth centres

A study published last year in the British Medical Journal has helped garner support for freestanding birth centres. The study analyzed 64,538 births in England and reported that compared to women who gave birth in hospitals, women in freestanding birth centres experienced fewer medical and surgical interventions. For example, only 3.5% of low-risk women who started their labour in a freestanding birth centre underwent a Caesarean section, compared with 11% of women who started their labour in hospital.

In all settings, the risk of a serious complication associated with childbirth was low, but the risk of a serious complication for the baby was slightly higher with home births than it was with hospital births. In some analyses, the risk of a serious complication was also higher when women started their labour at a freestanding birth centre. Overall, the study was not large enough to conclusively answer the question of whether care provided in freestanding birth centres is as safe as hospital care or not.

Will birth centres reduce costs?

Many news reports following the birth centre announcement claimed that birth centres are expected to reduce health care costs. What is the evidence for this?

In Ontario, midwives and obstetricians are paid under very different models. In 2006, midwives were paid between $2,500 and $3,000 (plus an additional 18% in lieu of benefits) for a full course of prenatal, delivery and postnatal care. Midwives in Ontario are currently restricted to attending only 40 births per year as the primary midwife and another 40 as an assistant, and the average annual income for a midwife is less than $100,000.

In contrast, obstetricians are paid about $35 for each prenatal visit and $500 for an uncomplicated vaginal delivery. However, obstetricians have no limit to the number of deliveries they can attend, and many deliver several hundred babies per year. Obstetricians also take care of women with high-risk pregnancies, perform Caesarean sections and provide gynecological care. So even though obstetricians are paid less for each birth, the median income for an Ontario obstetrician, before accounting for overhead, is over $400,000.

However, the financial argument for freestanding birth centres also focuses on reducing the costs associated with hospital care. Childbirth accounts for about 10% of what hospitals spend on inpatient care, and if birth centres decrease the likelihood of Caesarean sections and other interventions then the shift away from hospitals may markedly lower costs. Notably, the Caesarean section rate in Ontario is 28%, nearly twice the rate recommended by the World Health Organization. However, if a substantial proportion of women who plan to deliver at birth centres need to be transferred to a hospital—and in the British Medical Journal study about 1 in 5 women did—then birth centres may paradoxically result in higher costs.

More evidence needed

The Ministry of Health and Long-Term Care frequently asks the Medical Advisory Secretariat – now an arm of Health Quality Ontario – to prepare evidence-based analyses of new health technologies or new ways of delivering care, before instituting major policy changes. However, despite the government’s claim that birth centres are “good quality health care for good value,” the Medical Advisory Secretariat was not asked to assess the evidence related to birth centres.

Since details about how the Ontario birth centres will operate have not been made public, it is unclear whether evidence from other jurisdictions can be extrapolated to Ontario. For example, the authors of the British Medical Journal study noted that in England there are “clear referral pathways to obstetric units if complications occur, using a comprehensive ambulance network with trained staff.” Similarly, whether birth centres increase costs or save money depends to a considerable extent on how they are funded and on how much midwives are paid.

Closer to home, Emanuelle Hébert, a practicing midwife in Quebec and professor at Université du Québec à Trois-Rivières notes “the major problem with the Quebec birth centres has been that since their founding in the 1990s there has been little data collection.” When asked to provide details about how Ontario’s birth centres will be evaluated, the Ministry of Health and Long-Term Care did not provide with a comment by press time.

Do you think that birth centres will provide good quality maternity care at a lower cost?

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  1. Tom Auger

    For me the question of “cost” is quite secondary. I think birth centres are an excellent initiative. The more we can move away from “medicalized” childbirth, the better we are in general. The problem with alternative childbirth within the confines of a hospital ward is the inevitable conflict that happens between the medical team and the alternative team. In some hospitals, Toronto East General as an example, the integration is quite good, and a number of midwives operate out of that hospital. My own experience was with St. Michael’s hospital in Toronto and it was a very stressful experience. The medical team was pushing for all sorts of interventions, which was in conflict with our own wishes and the advice of the alternative team.

    Doesn’t it come down to insurance and the CYA principle (cover your assets)? Hospitals need to control as much as possible in order to meet their SLAs whereas alternative childbirth certainly allows for more variance within the birthing process.

  2. BigDuke6

    Any costing of these centers must of course include the costs of treating the inevitable catastrophes that, as surely as the moon rises and the sun sets, will come.

    NICU care for an infant with asphyxia, lifetime care for CP/Seizure/G-Tube patients produced as a natural byproduct of the process of birth and our society’s inability to accept death…hope the economists remember all that stuff too.

    As a frontline provider you learn about the inevitable natural outcomes. I have seen them in the labor wards, the pediatric wards, and the clinic. And having worked in the third world you quickly learn the advantages of “medicalized” childbirth. No one needs to explain that to a third world mother with a dead baby stuck in the birth canal with shoulder dystocia cuz no c-section was available.

    • Amanda

      The problem with this thought process is that it still buys into the process of medicalized birth as being the most progressive and best choice for birthing practices. The reality is that these problems you’ve listed are a rarity afforded to an extremely small percent of births, but that percentage often goes up when that birth is in the hospital as medical staff prescribe intervention methods that are not necessary and cause distress and harm to a child as a result. Out of hospital birthing centres are designed to limit that risk by stopping the medicalization of a process that often needs no medical interference what so ever.

      A dead infant stuck in the birth canal is a tragic thing. Medicalized birth, especially a c-section, is not the only way to prevent or deal with that that, and it most certainly won’t be the least invasive method with the lowest risk to both child and mother.

    • Lindsey p

      You are right there are thousands of women around the world who lose their babies because they don’t have access to c/s and here a c/s is always looked as a bad thing or the mom as a failure. Instead we should be thankful for them and be great ful that we have this option here in North America. Thank you for bringing this thought forward.

  3. Skye

    It’s not accurate to compare the midwife’s salary to the OB’s salary for a course of care in a normal birth. If a birth is uncomplicated, then one midwife will attend the woman from the start of active labour until 3-4 hours after the baby is born. A second midwife will arrive shortly before the birth to assist with delivery and look after the baby and leave a few hours after (cost: approximately $200, according to the 2010 Compensation Review of Midwifery). There are a total of 2 health care professionals involved (if no pain medication is required). This is the same if the birth is at the home or the hospital.

    An OB checks in with a woman every few hours in labour, and supervises her care and delivers the baby, while the nurses monitor the labour and provide labour support and fill the role of receiving and looking after the baby and provide after care. %featured%Nursing care during the entire labour is essential to the delivery of the baby and to the OB being able to deliver several hundred babies a year.

    Let’s not make nursing and nurses invisible, or pretend that OB’s manage labour and delivery all by themselves.%featured%

  4. Lindsey p

    Has anyone considered that this article came from the UK where midwives under go more intense training then the midwives here in canada do. In the Uk midwives are highly skilled health care providers compared to the midwives here. And in my experience in working with midwives here in canada they are only trained in the normal uncomplicated birth, but in my professional experience no birth is with out risk or complications and the midwives just don’t have the critical thinking to deal with these situations. I would like to see canada take on a UK model of training for midwives if free standing birthing centers are going to be opened. The general public has NO idea that they are trained differently and that the are lacking knowledge!

    • Alex D

      I am not sure what you are talking about. Midwifery training in the UK is three years as compared to 4 years here in Canada. Midwives here are very highly skilled. Part of that skill is knowing very well when to refer to more appropriate (i.e. obstetrical) care.

  5. Dr. Einhander

    I absolutely love the midwifery lobby’s demonizing of medical obstetrical care.

    They are trying to convince the general public that pregnancy and birth is “natural” and all blueberry muffins!

    Most people out there do not understand how wrong pregnancy and birth can go. I’ve seen it on too many occasions to count: one minute everyone is excited and happy, and the next they’re crying in the hallway because the cord prolapsed and the baby might die. Midwifes cannot deal with these complications as well as an obstetrician.

    As a physician, I demand that patients receive the best care possible. Midwives are not the best care possible (I think they are a dangerous redundancy whose existence is maintained by granola-style, anti-science PR). To consider cost as the primary motive for increasing the encroachment of midwives is unethical and dangerous!

  6. Alishah Merchant

    Midwifery care is more thorough and patient focused. For my first I had a midwife and for my second I had an OB. My OB visits consisted of a 2 hour wait with 1 min face time with the nurse and 1min face time with the OB. My visit with my midwife was 45 mins long. All my issues, concerns and questions were addressed in detail. My post partum care with my midwife was excellent. She helped me with my stitches care and pain. My midwife followed me regularly for 2 weeks after my birth. With my OB I ended up in emerg due to extreme pain from my stitches and my knots were irritated and needed to be cut out.

  7. Bethany

    The article fails to cut from that $400,000 the cost of the RN, secretary, office equipment, rent of office space. Plus I’d like to know the difference in insurance that each member pays, I’ve heard that the OBGYN pays HUGE insurance which again, is not covered. I think that midwives have it good here in Canada. %featured%What they need to do is put mid-wives INTO the hospitals instead of nurses in maternity floors, this is what they do in Australia. This may decrease the need to call the physician in many cases and much more cost effective. Allow the “regular” nurses to take the easier cases and give the midwife to the more difficult patients.%featured%

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