Ontario’s Maternity Care Expert Panel Recommendations and Next Steps

Best Start Annual ConferenceJanuary 17, 2006

For Discussion Only

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Background

• Created by the Ontario Women’s Health Council in October 2004 to address concerns about the quality and sustainability of maternity care in Ontario.

• Multi-disciplinary 15-member panel of professionals and a consumer

• Report to identify the status of maternity care in the various regions across the province and to provide recommendations for access and accountability in maternity care.

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OMCEP Vision and Scope

OMCEP Vision

Every woman in Ontario has access to high quality, woman and family-centred maternity care as close to home as possible.

Scope

The panel is developing recommendations for a coordinated province-wide system of essential maternity-care services.

Continuum of Maternity Care

Maternity care begins with pre-conception counseling, continues with prenatal, labour and birth care, and concludes with services to mother and newborn until approximately 6-weeks/2-months after birth.

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OMCEP Research

Hospital Demographics Survey – 109 Hospitals in Ontario that provide or recently ceased providing maternity care

• Literature Reviews and Environmental Scans:• Women’s Input into Maternity Care

• Human Resources Planning

• Models of Maternity Care

• Legislation/Regulation of Maternity Care

• Remuneration and Funding Schemes

• Liability Insurance

• Data and Evaluation Systems

• Focus Groups – consumer, provider, hospital staff, shared research findings

• Stakeholder Input

5OMCEP Interim RecommendationsGuiding Principles

• Pregnancy and Birth as a Normal Physiological Process • Equitable Access/Close to Home • Co-ordinated Access to High-risk Care, when needed • Woman and Family Centred Care - Empowerment and Participation• Informed Choice• Choice of Birthplace• Care Across the Continuum of Maternity and Newborn Care• Valuing Maternity Care Providers• Continuity of Care• Collaboration – inter-professional, respectful and seamless• Quality Care including to Diverse Populations• Effective Coordination of Services• Provider Preparation, Competence and Confidence• Continuous Evaluation and Improvement• Maternity Care as Essential Component of Primary Care • Alignment of System with Nat. and Internat. Determinants of Health• Financial Responsibility and Accountability

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Collaboration

Care and services across the maternity care continuum are, by their very nature, collaborative. Quality care depends upon:

• Sequential and concurrent communication and participation • across continuum

• low to high-risk care

• Multiple provider groups, learners and others

• Integrated services by transport, laboratory, imaging and pharmacy

• Institutional and community agency services and support by hospital staff, public health, child welfare, educators, lactation, others

• Emerging IT initiatives – telecare and consultation, info systems

• Services delivered within models that are considered ‘uni-professional’ and ‘inter-professional’ (most responsible person, MRP)

• Supported by coordinated, integrated funding, regulatory and insurance schemes at the ministry/provincial level

7OMCEP Findings Human Resources Planning

Obstetrical Human Resourceswith Trendlines to 2007

-500

0

500

1000

1500

2000

2500

3000

3500

1981 1985 1989 1993 1997 2001 2005

Family Practice

Obstetricians

Midwives

Linear (FamilyPractice)

Linear (Obstetricians)

Linear (Midwives)

8OMCEP Findings Mapping of Institutional Birth Activity

9OMCEP Research Findings Mapping of Institutional Birth Activity

10Spontaneous Labour and Unassisted Vaginal Birth in Ontario

Women Having Spontaneous Labour and Unassisted Vaginal BirthsOntario- Maternal and Institutional LHINs 2003/04

0

20

40

60

80

100

Per

cen

tag

e o

f W

om

en G

ivin

g B

irth

in

Ho

spit

al

% Women - Maternal LHIN 31.5 31.8 29.3 27.9 24.1 40.3 33.2 30.6 31.8 39.2 26.2 27.9 28.1 33.9 31.8

% Women - Institution LHIN 31.5 32.3 29.1 27.9 24.2 47.8 33.3 27.1 30.8 43.9 26.1 27.6 28.1 34.2 31.8

# Women - Maternal LHIN 42,097 2,199 2,705 2,206 3,222 4,005 3,761 3,993 5,336 5,844 1,088 3,452 1,176 1,694 786

# Women - Insitution LHIN 42,409 2,127 2,794 2,075 3,247 3,590 3,862 5,090 5,238 5,963 1,060 3,740 1,159 1,681 783

Total Erie St. Clair South West Waterloo HNHB Central WestMississauga

HaltonToronto Central Central Central East South East Champlain

N. Simcoe Muskoka

North East North West

Notes:Includes women whose labours were not induced and who had an unassisted vaginal birth."Maternal LHIN" refers to the mother's place of residence. Women from out-of-province or whose postal code was not known were excluded. Therefore, there are fewer women in this group than in the "institutional LHIN" group. "Institutional LHIN" refers to the location of the birth.

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Physician Intrapartum Volumes

Ontario Obstetricians/Gynaecologists & Family Physicians Average & Total Numbers of Birthing Women Attended

Ontario & LHINs 2003/04

0

50

100

150

200

250

300

350

Avg

. N

o.

of

Wo

men

Att

end

ed p

er P

hys

icia

n

Average # of Women Attended per FP 21.3 23.8 17.8 22.5 18.4 24.4 40.6 21.4 27.8 23.0 21.6 27.5 14.6 16.7 15.6

Average # of Women Attended per OB/GYN 215.3 232.2 213.4 257.6 211.7 260.8 339.6 170.7 248.1 211.5 150.2 175.7 204.4 186.1 197.6

# of Women Attended by FPs 15,541 381 1,534 766 1,340 974 1,259 1,538 1,027 1,515 604 1,705 979 966 953

# of Women Attended by OB/GYNs 106,351 6,037 7,042 5,925 11,007 5,477 10,528 15,359 14,638 11,630 1,502 10,192 2,862 3,164 988

Total Erie St. Clair South WestWaterloo Wellington

HBHB Central WestMississauga

HaltonToronto Central

Central Central East South East ChamplainN. Simcoe Muskoka

North East North West

Note: Only physicians who billed for more than one delivery are included

12Services to Diverse PopulationsBarriers

•Rural and Remote – • Human resources shortages

• Some hospitals at risk of closure, maternity care programs under pressure

• Access issues pervasive

• Reduced services – primary health care and primary maternity care, paediatrics, anaesthesia, well woman and newborn care

• Evacuation and associated risks

13Services to Diverse PopulationsBarriers – cont’d

•Aboriginal• Above plus disconnected services between Aboriginal

and non-Aboriginal programs, federal and provincial Aboriginal programs

• Urban Aboriginal populations

•Diverse populations• Interpretation

• Antenatal, sexual and public health education

• Socio-economic disadvantage

• Transportation

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Population-based Planning

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Population-based Planning cont’d

Projected Population, Ontario Regions 2004, 2016 and 2031

5.7

2.7

1.6 1.6

0.60.2

6.9

3.1

1.8 1.7

0.5 0.2

8.1

3.6

2.1 1.9

0.5 0.2

0123456789

Millions

2004

2016

2031

Adapted from Statistics Canada, 2004, and Ontario Ministry of Finance projections (Reference scenario).

16OMCEP Interim RecommendationsHuman Resources Planning

• to monitor and anticipate the health needs of Ontarians and make recommendations on the appropriate supply, mix and distribution of health human resources to meet those needs.

• broad education/promotion campaign to promote birth as a normal physiological process for women and timely access to high risk services, when needed

• intrapartum care as a positive career choice for providers

• coordination between provincial maternity care human resources planning and regional/local institutional, community and provider programs across the continuum

17OMCEP Interim Recommendations Education and Training

• Maximize capacity of maternity care provider program entrant class sizes, residency positions and clinical placements for midwifery, family med, nursing and OB

• Maternity care (incl. normal intrapartum) as a core part of curriculum

• Central provider and teaching registry

• Funded continuing education for providers in low-volume communities

• Inter-professional preparatory, post grad and continuing education opportunities

• Inter-professional modeling in clinical education placements

18OMCEP Interim Recommendations Recruitment and Retention

• Incorporate best practice re: retention and recruitment incentives into maternity care system

• Value maternity care providers - social, professional and compensation

• Under-serviced area support and recruitment

• Support confidence and competence through evidence-based continuing education, especially in low-volume situations

• Incorporate discourses and research on understanding risk and risk tolerance/management into provincial strategy to reduce provider stress

19OMCEP Interim Recommendations Models of Maternity Care

• Models are evolving in communities in response to access to care issues

• Model’S’- We confirmed that one model does not fit all Ontario situations

• Local model solutions, as identified by communities, are needed• Approximately 8 existing models of maternity care currently being

delivered in Ontario – current barriers present to using providers to full extent of scope

• An additional 15 models surveyed from existing proposals and other provinces will be recommended in ‘menu’-style inventory

• Inter-professional models are seen as positive option (not single solution)

• Model development and implementation to become part of regional maternity care planning (with regions/LHINs)

20OMCEP Interim Recommendations Maternity Care System Structure

• Provincial Coordination and LHINs

• Legislation and Regulation

• Funding

• Risk Management and Liability Insurance

21Maternity Care System StructureProvincial Coordination and LHINs

OMCEP’s premise:

Ontario must establish and maintain a coordinated Ministry-mandated provincial plan for maternity care to provide the foundation for a sustainable system. The proposed system will be monitored and coordinated at the provincial level and be dynamically adaptable to the needs of local communities in consultation with Local Health Integration Networks, local/regional stakeholders and service recipients.

22Maternity Care System StructureProvincial Coordination and LHINs

• Provincial unit, Maternity Care Ontario• Supported by steering committee and 6-region structure

with complementary permeable boundaries to LHINs• Boundaries support regional referral patterns and sharing

of resources • Build capacity in all 6 regions to plan for continuum of

maternity and newborn services – maximise complementary contributions by existing Regional Perinatal Programs

• Stakeholder and consumer input across the continuum of programs that contribute to maternity care

23Maternity Care System StructureLegislation and Regulation

• Barriers re: scopes of practice and institutional governance that are interrupting access and decreasing quality

• OMCEP Recos focus on Ministry-mandated omnibus approach to leg/reg maintenance across maternity care sector

• Increased scope (in selected authorized acts) for midwives and nurses in remote areas

24Maternity Care System StructureFunding and Remuneration

• Total sector expenditures over $1B

• No provincial envelope, standard reporting or accountability for maternity services sector, most expenditures blended into larger budgets

• Barriers re: disconnected funding schemes for FFS, Alternate payment, Midwifery, Nurse Practitioners, Hospitals

• Lack of equity between providers, groups and programs resulting in decrease in quality, access and provincial uptake of services

• OMCEP Recos focus on improved accountability, equity, coordination and efficiency through planning

• Maternity Care Ontario would coordinate funding streams in Ministry and work with LHINs to improve accountability at regional/local levels

25Maternity Care System StructureRisk Management and Liability Insurance

• Current expenditures on provider liability insurance over $60M (reimbursements for obstetricians, family physicians and midwives only)

• Competition between insurers and risk averse practice (vs. EBP) driving care and recruitment and retention pressures

• OMCEP recommendations focus on risk tolerance/management strategy at provincial level in coordination with regional maternity care plans

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Women’s Input/Access to Care

•OMCEP approach is to recommend women’s input at all levels of maternity care system

• Provincial, regional, community, institutional and provider levels

•Maternity Experience Survey – to be developed

•LHIN linkages with women’s organizations

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Data and Evaluation

• OMCEP Logic Model

• Survey of Maternity Care Indicators

• Linking of Niday with Midwifery Data providing province’s first complete set of perinatal data

• Evaluation Plan to continue to bridge data sources for ongoing monitoring:

• Ontario Hospital Reports Collaborative

• Hospital Costing

• Public Health

• Women’s Experience of Maternity Care

• Management Information System to support Maternity Care Ontario

Vision: Every woman in Ontario has access to high quality, woman and family-centred maternity care as close to home as possible.

Maternity Care Providers / Provider Agencies

Regulatory and Insurance Bodies

Health Professional Education System

Involve women in the planning, delivery and evaluation of services

1. High levels of women satisfaction

2. Healthy prenatal processes

3. Appropriate use of obstetrical interventions

4. Good clinical outcomes (maternal & child)

5. High levels of patient safety

Provide high quality, safe and comprehensive services across the continuum of mat care

Women access maternity services according to the level of care required

Create and support innovative and responsive models of maternity care, including collaborative practice.

Engage in preparatory, continuing, and advanced inter-professional education for competency

Promote a range of inter-professional, collaborative, and other practice models.

Regulate and protect the public interest in a manner that permits and promotes the range of provincial maternity care models

Permanent provincial coordinating body responsible for maternity care services

MOHLTC and other Relevant Ministries

Women using Maternity Care Services

Provision of safe, high quality care across the full continuum of maternity care services

Provision of integrated, coordinated maternity care services

Efficiently delivered maternity care system with appropriate supply and distribution of providers

Allocate funding for:-education training spots-Maternity care services

Establish payment mechanisms and incentivesEngage in HR planning

Out

puts

Improved maternal and child health

6. System supports a variety of high quality, evidence-based service delivery models

7. Maternity care is provided as close to home as possible

8. Small/rural/remote communities meet population needs for maternity care services

9. Maternity care system assesses and addresses the unique needs of diverse and vulnerable populations

10. Sufficient inter-professional education and training spots (preparatory, continuing & advanced skills) to meet population needs.

11. Sustainable network of clinical teachers and placements

12. Maternity Care is an attractive career option for new and existing providers

13. Recruitment, retention and distribution of maternity care providers are appropriate to population need

14. Regulations, funding and liability insurance systems are harmonized (a) within provider groups and (b) across provider groups

15. Efficient and responsible program funding expenditures

Women satisfied with maternity services

Improved access (to appropriate care provider)

Inp

uts

Act

ivit

ies

shor

t-m

ediu

m

Out

com

es

long

1 2 543

6

7 8 9 10 11

12 13 14

18171615

19 2021

22

Accountable use of system resources

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Next Steps

• Stakeholder outreach and consultation

• Ministry briefing

• Finalize Draft Report

• Presentation of Final Report to OWHC