As the data at BORN continues to accumulate for its primary purpose of facilitating and improving care in Ontario, secondary use of that data for research is also increasing. The BORN Data Analysis and Research Team (DART) is comprised of researchers/investigators, data analysts, epidemiologists, research analysts, research and data request coordinators, a knowledge translation specialist, and graduate students. In addition to the regular work of provincial surveillance and reporting, this team initiates research projects and supports and contribute to external projects.
In the two fiscal years of this report BORN has implemented three large mixed-methods research projects. The Maternal Newborn Dashboard project is examining change in clinical practice across all hospitals in Ontario associated with six key performance indicators. We are exploring why some hospitals change dramatically, some minimally, or others not at all. Quantitative methods measure actual change and qualitative methods help us discover more about why change does or does not occur.
When the government funds new initiatives, BORN often bids to do the evaluation. In the time period of this report we have been evaluating the implementation of the MoreOB program (Managing Obstetrical Risk Efficiently) across Ontario hospitals as well as completing an evaluation of the first year of the new Birth Centres in Toronto and Ottawa. Results for both of these projects will be available in the coming year. Key findings of the Birth Centre Evaluation are highlighted in the green box below.
For externally-driven projects, BORN works closely with provincial and national groups who want to use the data. With about 140,000 births per year, the sample size and power of the data is impressive! For example, in the two fiscal years of this report, BORN data has been used:
- in linkage with the Canadian Neonatal Network to determine the neonatal level of care required for very preterm babies at 30 and 31 weeks in the Greater Toronto Area
- in partnership with Newborn Screening Ontario to help predict gestational age of a baby via an innovative method using the blood spot obtained shortly after birth
- by the Greater Toronto Area network to determine if the risk of gestational diabetes is greater in multiple pregnancy
- by PhD students - one looking at the relationship between prenatal screening tests and in-vitro fertilization (IVF) and the other looking at the relationship between influenza vaccination and perinatal outcomes (see the 'Research Spotlight' box below)
This brings us to a particular highlight in this period. We completed the first transfer of BORN data to ICES the Institute for Clinical Evaluative Sciences (ICES)! Now researchers who need complex linkages between perinatal and other administrative datasets have access to this resource such as the influenza one described above. Approvals for use of these linked datasets are underway.
BORN is open to supporting research! Please drop us a note at firstname.lastname@example.org or give us a call. We are happy to work with you to answer questions to help improve maternal child care.
Birth Centre Evaluation: Funded by the Ontario Ministry of Health and Long-term Care (MOHLTC), two midwifery-led birth centres (BCs) in Toronto and Ottawa opened in January of 2014. BORN Ontario conducted the evaluation of the first year of operations at these centres. We measured indicators of quality and safety of care, client satisfaction and integration with the existing obstetric care community. Preliminary cost calculations were also completed. A final report was submitted to the MOHLTC in March of 2016.
Care in the BC’s was low in intervention, safe (minimal negative outcomes and a transport rate comparable to the literature), well-integrated into the maternal-child health system, and satisfactory to women. From an economic perspective, fewer interventions in the BC cohort demonstrate potential cost savings to the system (with recognition that start-up costs and occupancy rates need further investigation to gain full understanding of the economic impact).
Of the 495 women admitted to a BC during the pilot year, 87.9% (435/495) experienced a spontaneous vaginal birth, regardless of the eventual location of birth, and 7.7% (38) had a cesarean birth. While 374 (75.5%) of women planning to give birth at the BC ultimately did so, 26.3% (130/495) of mothers or babies required transport to another level of care. Rates of intervention (epidural, labour augmentation, assisted vaginal birth, and cesarean section were significantly higher in a matched cohort of midwifery clients who began labour planning to deliver in hospital. When controlled for two clinical circumstances that could confound the outcomes (previous cesarean birth and BMI (< 30 and ≥ 30), the risk ratios were still higher for all interventions in women giving birth in hospital with the exception of NICU admission.
The findings from this evaluation are consistent with evidence about midwifery care in general and out-of-hospital birth both in Ontario, Canada and internationally. In the first year of operation, care was consistent with national guidelines, and morbidity and mortality rates and intervention rates were low. This evaluation validates good quality care and safety of the Ontario Birth Centres for women with low-risk pregnancies seeking a low-intervention approach to their labour and birth. As the number of births grows, further evaluation will be required to confirm these findings.
Research Spotlight: Deshayne Fell (BORN Epidemiologist from 2009 to 2016) recently finished two projects using BORN Information System (BIS) data linked with health administrative databases at the Institute for Clinical Evaluative Sciences (ICES). The first (part of her PhD) used two years of linked BORN-ICES data to assess whether 2009 pandemic influenza in mothers (determined by the ICES databases) was associated with any increased risk of preterm birth (determined by BIS data). She found that although there was no increased risk in the overall obstetrical population, women with conditions that place them at higher risk for more serious influenza-related complications (e.g., pre-existing asthma, cardiovascular disease) had a significantly increased risk, especially in later pregnancy.
The second study, funded by the Canadian Institutes of Health Research (CIHR), followed a one-year birth cohort of infants (from the BIS) to assess whether rates of influenza-coded health care encounters during the first year after birth (in ICES) were different in infants born to women who received pandemic H1N1 vaccine during pregnancy, versus those born to unvaccinated mothers. The study did not find any differences in rates of infant influenza during the late pandemic time period, nor in any other subsequent time period (Fell DB et al., PLOS One 2016;11:e0160342). Deshayne had also done quite a few earlier influenza-related studies, including one using BIS data (Fell DB et al., Am J Public Health 2012;102:e33-40).
As a result of these contributions, in 2014 she was invited to join a WHO Taskforce on influenza vaccination during pregnancy and continues to be involved in numerous reports and presentations as part of that Taskforce.