Hospital Births in Canada: A Focus on Women Types of Care

Hospital Births in Canada: A Focus on Women Types of Care
Hospital Births in Canada: A Focus on Women
Living in Rural and Remote Areas
Types of Care
Our Vision
Better data. Better decisions.
Healthier Canadians.
Our Mandate
To lead the development and
maintenance of comprehensive
and integrated health information
that enables sound policy and
effective health system management
that improve health and health care.
Our Values
Respect, Integrity, Collaboration,
Excellence, Innovation
Table of Contents
About the Canadian Institute for Health Information ................................................................... iii
Acknowledgements .....................................................................................................................v
Executive Summary .................................................................................................................. vii
About This Report ...................................................................................................................... xi
Introduction ................................................................................................................................ 1
Important Notes About This Report ........................................................................................ 5
Accessing Hospital-Based Maternity Services............................................................................ 7
How Long Does It Take for Women to Reach Their Hospital of Birth? ...................................10
Are Women From Rural Areas Delivering in Urban or Rural Hospitals? .................................14
How Often Do Rural Deliveries Involve a Transfer From One Hospital to Another? ...............14
Women Who Deliver in Hospital ................................................................................................15
How Do Urban and Rural Women Differ by Age, Parity, Risk and
Socio-Economic Status?........................................................................................................15
Mode of Delivery....................................................................................................................21
Providers...................................................................................................................................24
How Do Urban and Rural Women’s Providers of Intrapartum Care Differ? ............................24
Maternal and Infant Outcomes ..................................................................................................30
How Do Outcomes Compare for Urban and Rural Women? ..................................................30
How Do Outcomes for Rural Women Vary Across Canada’s Health Regions? ......................36
Do Outcomes for Rural Women Vary by Time Travelled to Delivery? ....................................45
Do Outcomes for Rural Women Vary by Urban Versus Rural Hospital of Birth? ....................47
Conclusion ................................................................................................................................48
Appendix: Odds Ratios and Associated Confidence Intervals for Maternal
and Newborn Outcomes ...........................................................................................................49
References ...............................................................................................................................51
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
About the Canadian Institute for
Health Information
The Canadian Institute for Health Information (CIHI) collects and analyzes information on health
and health care in Canada and makes it publicly available. Canada’s federal, provincial and
territorial governments created CIHI as a not-for-profit, independent organization dedicated to
forging a common approach to Canadian health information. CIHI’s goal: to provide timely,
accurate and comparable information. CIHI’s data and reports inform health policies, support
the effective delivery of health services and raise awareness among Canadians of the factors
that contribute to good health.
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Acknowledgements
The Canadian Institute for Health Information (CIHI) would like to acknowledge and thank the
many individuals and organizations that contributed to the development of this report.
Particularly, we would like to express our appreciation to the members of the Expert Group who
provided invaluable advice throughout the process:
• Ms. Rosalie Case, Executive Director, Rural and Suburban Hospital Services and Supports,
Community and Rural, Primary Care and Chronic Disease Management, Alberta Health Services
• Dr. Joan Crane, Maternal Fetal Medicine Specialist, Eastern Health; Professor of Obstetrics
and Gynecology, Memorial University of Newfoundland
• Dr. Stefan Grzybowski, Professor, Department of Family Practice, and Co-Director, Centre
for Rural Health Research, The University of British Columbia
• Dr. Maureen Heaman, Professor, Faculty of Nursing, and Associate Professor, Department
of Obstetrics, Gynecology and Reproductive Sciences, Faculty of Medicine, University of
Manitoba; Canadian Institutes of Health Research Chair, Gender and Health
• Dr. Brian Postl, Dean, Faculty of Medicine, University of Manitoba
• Ms. Carla Skauge, Coordinator, Northern Women’s Health Program, Northwest Territories
and Western Nunavut, Stanton Territorial Health Authority
• Dr. Alan Thomson, Consultant Physician
In addition, we would like to acknowledge and express our appreciation to the Sparsely
Populated Regions Advisory Group for its advice:
• Mr. Fraser Bell, Vice-President, Planning, Quality and Information Management, Northern
Health Authority, British Columbia
• Ms. Helga Bryant, CEO, Northern Regional Health Authority, Manitoba
• Dr. Randall Fransoo, Research Scientist, Manitoba Centre for Health Policy, and Assistant
Professor, Department of Community Health Sciences, University of Manitoba
• Ms. Cecile Hunt, CEO, Prince Albert Parkland Health Region, Saskatchewan
• Ms. Kay Lewis, CEO, Stanton Territorial Health Authority, Northwest Territories
• Dr. W. Alexander Macdonald, Territorial Chief of Staff, Department of Health and Social
Services, Nunavut
• Dr. Martha MacLeod, Professor, Nursing and Community Health, and Chair, School of
Nursing, University of Northern British Columbia
• Ms. Shelly Pusch, Senior Vice President, North Zone, Alberta Health Services
• Ms. Heather Toporowski, Vice President, Community and Rural Primary Care and Chronic
Disease Management, Alberta Health Services
• Ms. Beth Vachon, CEO, Cypress Regional Health Authority, Saskatchewan
• Ms. Sherri Wright, Assistant Deputy Minister, Health Services, Department of Health and
Social Services, Government of Yukon
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
The CIHI project team responsible for the development of this report is as follows:
• Marilee Allerdings, Manager
• Xi-Kuan (Sean) Chen, Program Lead
• Denise Cullen, Classification Specialist
• Walter Feeney, Program Lead
• Sam Herold, Senior Analyst
• Maria Hewitt, Special Projects Lead
• Jin Huang, Senior Analyst
• Louise Lalonde, Manager
• Anne McFarlane, Vice President
• Tony Mottershead, Special Projects Lead
• Joanne Sefton, Program Consultant
• Adam Sherk, Senior Analyst
• Brandon Wagar, Methodologist
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Executive Summary
Ensuring the adequacy of services for pregnant women who live in Canada’s rural and remote
areas can be a challenge for health planners. Communities with few births may not be able to
support the array of complex care required by mothers and their newborns. Pregnant women in
such communities often face the prospect of travelling great distances to deliver, especially if
identified risk factors suggest they will need intervention by a specialist. This report provides
information about the delivery experience and birth outcomes of women from rural and remote
areas who gave birth in hospitals across Canada over a five-year period. The purpose of the report
is to assist health care decision-makers as they plan services for women and newborns in their
health regions and jurisdictions.
From 2007–2008 to 2011–2012, there were 242,550 in-hospital deliveries for women from rural
areas in Canada (excluding Quebec), representing 18% of all hospital deliveries. However, in
many of Canada’s health regions, especially those in the Far North, the majority of deliveries
were for women living in rural and remote areas. The following findings are based on the linkage
of hospital records of mothers to those of their live births for the five-year period 2007–2008 to
2011–2012 (excluding Quebec).
The Birth Experience
The intrapartum experience of rural women was quite distinct from that of their urban
counterparts—rural women were more likely to have lengthy travel times to give birth, to
experience a hospital transfer and to have their birth attended by a family physician rather than
an obstetrician/gynecologist. The majority (67%) of rural women gave birth in urban hospitals,
and 17% travelled more than two hours to deliver their baby.
Maternal Characteristics
Women living in rural areas had certain characteristics that placed them at increased risk of poor
maternal and infant birth outcomes, such as relatively high rates of teen births and living in socioeconomically disadvantaged neighbourhoods. However, from a pan-Canadian perspective, rural
women had a risk profile similar to that of urban women in terms of the prevalence of diabetes and
hypertension, either pre-existing or gestational.
Mode of Delivery
Women from rural areas were less likely than those from urban areas to have a Caesarean
section (25.6% versus 28.6%) or assisted vaginal birth (8.6% versus 10.6%), and they were
more likely to have a spontaneous vaginal birth (65.8% versus 60.8%).
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Providers
Deliveries for rural women were more likely than deliveries for urban women to be attended
by a family physician (44.8% versus 26.0%) and less likely to be attended by an obstetrician/
gynecologist (57.7% versus 79.1%) or midwife (4.0% versus 5.7%). i Among women with a
Caesarean section, rural women were less likely than urban women to have their birth attended
by an obstetrician/gynecologist (75.8% versus 97.7%).
Maternal and Infant Outcomes
After controlling for socio-demographic characteristics, comorbidity and aspects of the delivery,
the study found that
• While relatively rare in Canada, severe maternal morbidity was a somewhat more common
occurrence for rural women than for urban women (2.4% versus 1.7%; odds ratio [OR]
1.4; 95% confidence interval [CI] 1.3 to 1.4). Similarly, unplanned hospital readmissions
were rare, affecting 1.2% of urban women and 1.4% of rural women (1.4% versus 1.2%;
OR 1.2; 95% CI 1.1 to 1.2).
• Newborns born to women living in rural areas were more likely to be large for gestational
age (12.5% versus 9.4%; OR 1.4; 95% CI 1.4 to 1.4) but were less likely to be small for
gestational age (8.2% versus 10.3%; OR 0.7; 95% CI 0.7 to 0.7) or preterm (7.6% versus
8.1%; OR 0.9; 95% CI 0.9 to 1.0).
There was significant variation in these delivery and birth outcomes among rural health regions,
with some regions doing significantly better and others significantly worse; few clear regional
patterns emerged.
Travel time to delivery beyond two hours was associated with higher rates of preterm and large
for gestational age births among rural women. This could reflect success in referring high-risk
pregnancies from rural and remote areas to distant specialized care. It could also indicate that
lengthy travel times to delivery are a risk to pregnancies. The data available for this report
cannot distinguish between these potential explanations.
Rural women who delivered in urban hospitals had markedly higher rates of preterm birth than
those delivering in rural hospitals (9.7% versus 3.1%). This could potentially be due to effective
triaging of women at high risk of this outcome. However, this data cannot be used to explain the
observed differences.
Conclusions
From a pan-Canadian perspective, small but significant differences in birth outcomes of rural
and urban women were evident from 2007–2008 to 2011–2012, with some outcomes better
for urban women and babies and some outcomes better for rural women and babies. During
this period, rural women’s birth experiences were quite distinct from those of their urban
counterparts; for example, they were more likely to have lengthy travel times to deliver and
i. Percentages in this section sum to more than 100% because births may be attended by more than one type of provider.
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
were more likely to have intrapartum care provided by a family physician rather than an
obstetrician. There was significant variation in maternal and infant outcomes among rural
women across Canada’s health regions. Information from the administrative data used in this
report cannot fully explain this variation. The report’s findings can be used by health planners to
further explore their outcomes, taking into account regional differences in systems of care.
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
About This Report
This report follows the publication of a series of special reports prepared by the Canadian
Institute for Health Information (CIHI) on the health of and health care provided to Canada’s
mothers and infants. CIHI reports that address the care of women giving birth in Canada include
the following:
• In Due Time: Why Maternal Age Matters (2011)
• Highlights of 2010–2011 Selected Indicators Describing the Birthing Process in Canada (2012)
• Highlights of 2009–2010 Selected Indicators Describing the Birthing Process in Canada (2011)
• Highlights of 2008–2009 Selected Indicators Describing the Birthing Process in Canada (2010)
• Too Early, Too Small: A Profile of Small Babies Across Canada (2009)
Presents analyses of national preterm birth and small for gestational age rates and provides
information about the important health and risk factors associated with these occurrences.
• Giving Birth in Canada: Regional Trends From 2001–2002 to 2005–2006 (2007)
• Giving Birth in Canada: The Costs (2006)
Explores the costs associated with delivering maternity and infant care in Canada, including
provincial, national and international comparisons, where available.
• Giving Birth in Canada: Providers of Maternity and Infant Care (2004)
Focuses on trends in birthing and maternal and infant care and examines the changing
scopes of practice for care providers.
• Giving Birth in Canada: A Regional Profile (2004)
Provides selected health care and health status indicators for Canada’s mothers and infants.
These indicators include new data presented at the regional level for regions with
populations of 75,000 or more and at the provincial level.
Please visit www.cihi.ca to download a copy of any of these reports.
Each of these reports presents a fact-based compilation of current research, historical trends,
and new data and findings. Their aim is to assist care providers and decision-makers in
planning health services for maternity and infant care. They also complement CIHI’s ongoing
reporting process and the initiatives of partners such as the Canadian Perinatal Surveillance
System (CPSS).
The CPSS is part of the Public Health Agency of Canada’s initiative to strengthen national
health surveillance capacity. The CPSS monitors and reports on perinatal health determinants
and outcomes through an ongoing cycle of data collection and acquisition, expert analysis,
interpretation and communication.
In 2008, the CPSS released its Canadian Perinatal Health Report, 2008 Edition, which includes
information on 29 perinatal health indicators on determinants and outcomes of maternal, fetal
and infant health.5 Statistics for each indicator consist mainly of temporal trends at the national
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
level and provincial/territorial comparisons for the most recent year for which data is available.
The report Perinatal Health Indicators for Canada, 2011 was produced by CPSS6 to update
data on key perinatal health indicators described in the 2008 edition and to provide current
information on major determinants and outcomes of maternal, fetal and infant health in Canada.
The report is available on request by sending an email to [email protected]
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Introduction
Canada is characterized by its vast geography and widely dispersed population. Stretching east
to west from the Atlantic to the Pacific oceans and north to the Arctic Ocean, it is the secondlargest country in the world. Canada’s population, once predominantly rural, has become
urbanized, so that by 2011 only 18% of Canada’s population of nearly 35 million resided in a
rural or remote area (Box 1). These areas are often sparsely populated and disadvantaged in
terms of access to medical services.
Although the size of the rural population has declined, the birth rate among rural women is high
relative to that of their urban counterparts.7 Many rural women do not have ready access to
maternity providers and services in the wake of rural hospital closures and the regionalization
of maternity services.8–11 Health planners in each of Canada’s provinces and territories must
grapple with issues around providing vital delivery services to women in rural areas.
This report provides a profile of Canadian hospital-based deliveries with a focus on differences
experienced by women who reside in rural and remote areas. The concept of “rural” encompasses
aspects of population size, density, distribution, and distance to and relationship with urban areas
(for example, commuting patterns) (Box 1).
Box 1: Canada’s Rural Population
In this report, an urban area was defined as a census metropolitan area (CMA) or census agglomeration (CA) of
at least 10,000 residents.* Rural areas and small towns with a population of less than 10,000 persons (not in any
CMA or CA) were considered rural.
Census data for 2011 showed that 23,123,441 people, or 69% of the total population, lived in one of Canada’s
33 CMAs. In addition, 4,311,524 people (13%) lived in CAs and 6,041,723 people (18%) lived outside CMAs
and CAs.
The proportion of people living in rural areas has declined steadily over the past 160 years. It fell below the
50% mark between 1921 and 1931, due to major shifts within the Canadian economy from agricultural to
industrial sectors.
In 2011, only four provinces had a proportion of their population living in rural regions that was near to or lower
than the national average: Quebec (19.4%), Ontario (14.1%), Alberta (16.9%) and British Columbia (13.8%).
The proportion of the population living in rural areas was highest in the Atlantic provinces and in the territories.
Note
* CMAs and CAs are areas consisting of one or more neighbouring municipalities situated around a core. A CMA must
have a total population of at least 100,000, of which 50,000 or more live in the core. A CA must have a core population
of at least 10,000 (http://www12.statcan.gc.ca/census-recensement/2011/ref/dict/geo009-eng.cfm, accessed
November 26, 2012).
Source
Censuses of Population, 1851 to 2011, Statistics Canada.
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
As shown on the map in Figure 1, in most of Canada’s health regions ii (58 of 85 health regions
included in this analysis), more than 20% of hospital births involved women living in rural areas
during the study period. The 28 health regions with a high concentration of hospital births among
rural women (greater than 60%) were primarily spread across central and northern Canada. The
map shows marked variation across the territories in the extent to which rural women accounted
for all hospital births. In Yukon, relatively few (21%) deliveries were for rural women. The
remaining 79% were for women living in Whitehorse, the only urban city in Yukon. In contrast,
in the Northwest Territories, 55% of deliveries were for rural women. In Nunavut, there are no
urban areas; consequently all deliveries were for rural women. Across the provinces, the
percentage of hospital births accounted for by rural women ranged from 10% in Ontario to
46% in Newfoundland and Labrador.
Figure 1: Deliveries for Rural Women as a Percentage of All Deliveries, by Health Region,
Selected Provinces/Territories, 2007–2008 to 2011–2012
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
ii. The geographical units of analysis used throughout this report are the patient’s province and health region of residence. “Health
region” refers to administrative areas defined by the provincial ministries of health. For complete Canadian coverage, each of the
territories also represents a health region.
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
The first section of this report describes the experience of rural and urban women who delivered
live births in a hospital in terms of their access to hospital-based services. Differences in the
socio-demographic and health risk profiles of rural and urban women who gave birth are
described next. The following two sections characterize the mode of delivery and the clinicians
who provided care during labour and delivery. The last section presents analyses that compare
maternal and infant outcomes for urban and rural women and then focuses on how such
outcomes vary for rural women across Canada’s health regions.
The purposes of the report are to provide a pan-Canadian perspective on rural deliveries and to
generate information that can be used by local health managers and planners to improve care
and outcomes. The report identifies some of the unique attributes of the birthing experience of
rural women and highlights significant regional variation in selected maternal and infant
outcomes. It is the intention of the report to stimulate and inform local investigations to better
understand these observed sources of variation. Although the administrative data used to
generate the report’s findings plays an essential role in surveillance, this source of information
is often inadequate when trying to identify which of the many complex social, environmental,
health care and clinical factors contribute to local variation in health outcomes. A series of four
hypothetical vignettes are presented throughout the report to illustrate some of the challenges
faced by planners, providers and women giving birth in rural areas.
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Vignette 1: Perspective of a Rural Maternity Care Planner
Pam is the executive director responsible for planning and delivering acute care services for a rural region located
in western Canada. She has also worked as a maternity nurse and nurse manager in rural hospitals, and she
understands the challenges of providing birthing services for a large, sparsely populated region. She knows that
services in rural areas often rely on a few key people and that the service can be jeopardized if one of them leaves
and cannot be replaced.
A few years ago, Pam was seconded to the ministry of health to lead the review of strategies for supporting
birthing services in rural regions and the required back-up and transfer services. Her team considered a number
of questions:
• Would additional funding through negotiated physician agreements be effective in attracting and
retaining physicians?
• Would additional training for the health care team (nurses, physicians and midwives) support them to expand
or maintain their skills and confidence to provide safe care?
• What strategies can medical schools and midwifery and nursing programs adopt that will attract new
practitioners to and retain them in rural communities?
• What legal or regulatory changes are required to support the scope of practice required?
• What else is needed to support collaborative care and provide for a reasonable call schedule?
Since returning to the region, Pam has been working with the medical director to maintain birthing services at
the region’s two hospitals. They looked at where women from the region give birth and the quality of services
at the local hospitals. They launched a number of initiatives to support quality care, including participation in the
MOREOB Program. As well, the provincial perinatal program provided support for a number of other initiatives,
which included implementing new referral and transfer protocols for more specialized services. The local hospitals
and the community welcomed family practice residents—they hoped the experience would make the residents want
to live and practise in the community.
One of the region’s family physicians who performs Caesarean sections recently announced his retirement, and
Pam and the medical director are worried about finding a replacement. They have a potential candidate and know
that many regions will be competing for her. In addition, they understand that the candidate is looking for a better
work–life balance and does not want to be on call as much as the physician who is retiring. A midwife has also
expressed interest in moving to the community. Pam and the medical director are looking at what type of
collaborative care model can be implemented in their community to support the continuation of birthing services
at their hospitals.
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Important Notes About This Report
Data
Data for all in-hospital-based indicators was obtained from the Discharge Abstract Database
(DAD) at the Canadian Institute for Health Information (CIHI) for 2007–2008 to 2011–2012.
This data holding captures administrative, clinical and demographic information on inpatient
events from acute care hospitals in Canada. All provinces and territories submit to the DAD
except Quebec, which submits data to CIHI’s Hospital Morbidity Database.
Quebec’s ministère de la Santé et des Services sociaux submits a data file to CIHI at the end
of each year. This data does not contain postal codes, which prevented us from deriving
several key variables used in this report. Due to this limitation, information about residents of
Quebec is not reported here.
All provinces and territories that submit to the DAD use the International Statistical
Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA)
and Canadian Classification of Health Interventions (CCI).
This report presents data based on women’s place of residence, which may differ from the
place of hospitalization.
Several health regions have small numbers of deliveries per year. In order to maximize
region-level reporting, all results are for five years of pooled data.
This report is limited to hospital-based deliveries, as the vast majority of live births (98.5%) in
Canada take place in hospitals.12 The jurisdictions with the highest percentages of out-ofhospital births are Nunavut (6.4%) and the Northwest Territories (3.7%).
DAD records do not include information that permits us to identify deliveries for
Aboriginal women.
Analyses
Analyses of in-hospital deliveries and birth statistics, as well as logistic regression models,
were based on a population of live newborns who could be linked to their mothers. More
details on how this population was defined are provided in the Technical Notes, which can be
found online at www.cihi.ca.
All rates are crude unless otherwise stated.
The term “delivery” refers to a single in-hospital event in which one or more births occurred.
For example, a mother delivering twins would be counted as one delivery.
The term “birth” refers to a single in-hospital birth. For example, a mother delivering twins
would be counted as having two births.
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Geographical information for deliveries and births was derived from the maternal
delivery record.
MapQuest was used to calculate drive time, in minutes, between the mother’s residence and
the hospital in which she delivered. Deliveries where drive time could not be determined, but
for which the associated Vincenty distance was greater than the maximum observed Vincenty
distance in the 60-to-120-minute group, were assigned to the 121+ group. The Vincenty
distance is calculated as the crow flies using a formula that considers latitude and longitude
points on the Earth’s surface.
Maternal outcomes were identified throughout episodes of care. An episode of care refers to
all contiguous acute care hospitalizations. To construct an episode of care, transfers within
and between facilities were linked. Newborn outcomes were identified using information on
the birth record. Episodes of care for newborns were not constructed due to limitations in the
ability to link newborn records across time.
Analyses of newborn size—small for gestational age (SGA) and large for gestational age
(LGA)—were limited to singletons and twins only.
Health Region
The analysis included 85 health regions (all health regions in Canada excluding those in
Quebec). Region-level summaries provided throughout the report include 75 of these 85
health regions. Summaries exclude the following 10 regions because either the total number
of deliveries or the number of deliveries for rural women was too small:
• Fraser South, B.C.;
• Richmond, B.C.;
• Vancouver, B.C.;
• Fraser North, B.C.;
• Edmonton Zone, Alberta;
• Winnipeg, Manitoba;
• Brandon, Manitoba;
• Churchill, Manitoba;
• Mississauga Halton, Ontario; and
• Toronto Central, Ontario.
For more information on data and methods used for this report, please refer to www.cihi.ca.
Province-, territory- and health region–level results are available as supplementary
tables online.
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Accessing Hospital-Based Maternity Services
The birthing experience of women living in rural and remote areas of Canada often differs from
that of their urban peers. Hospital closures and the regionalization of perinatal services have left
many women in small and remote communities without an option for a local hospital-based
delivery. For example, 17 of the 98 acute care hospitals in Alberta lacked an elective obstetric
service in 2000.13 By 2004, the number of hospitals without such services had grown to 29.14
In rural B.C., 17 maternity care services closed between 2000 and 2007.15
Concerns related to cost, efficiency and quality of care may be raised when an area’s population
declines relative to its health care infrastructure. Analyzing these factors may lead to a decision
to close facilities or regionalize services. Retaining physicians and other health personnel in
rural communities following hospital closures can be difficult. And as older rural physicians
retire, some communities find it difficult to recruit new physicians to provide intrapartum care in
a rural setting that doesn’t have many colleagues to share the time-consuming, sometimes
unpredictable and potentially stressful responsibilities.
Rural and remote areas with few residents and births cannot usually sustain medically
supported maternity services. Pregnant women in these communities must travel outside of
their community to a facility offering such care before delivery, sometimes a great distance.
Other areas may be able to accommodate a low-risk pregnancy with local services but need to
refer high-risk pregnancies to hospitals with specialized services such as Caesarean section
(C-section) and neonatal intensive care capacity.
Some rural and remote communities have overcome resource challenges by developing
innovative multidisciplinary collaborative maternity services that engage the expertise of nurses,
nurse practitioners, midwives, specially trained family physicians and others in shared-care
maternity practices. Some communities without hospital-based elective obstetric services have
been able to accommodate low-risk pregnancies. For example, birthing centres have been
established in remote communities to permit delivery closer to home16, 17 (Box 2).
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Box 2: Birthing Centres Serving Remote Communities14
A birthing centre is a health care facility that provides labour and delivery services; it is generally staffed by
midwives. Four birthing centres have been established in Canada to provide maternal care services based in
traditional Aboriginal health and birthing practices, complemented by modern forms of medical care, in unique
manners specific to their respective community.
• The Inuulitsivik Health Centre in Puvirnituq, Quebec, was the first centre to open in 1986.
• The Rankin Inlet Centre in Nunavut opened in 1995.
• The Tsi Non:we Ionnakeratstha* Ona:grahsta’† Six Nations Maternal and Child Centre opened in Ohsweken,
Ontario, in 1996.
• The Kitikmeot Birthing Centre in Cambridge Bay, Nunavut, opened in 2010.
CIHI does not receive data from these centres, and births in these centres are not reflected in the analyses
presented in this report.
Notes
* “The place they will be born” in Mohawk.
† “A birthing place” in Cayuga.
A recent joint position paper issued by professional societies and organizations representing
obstetricians and gynecologists, midwives, nurses and family physicians highlights diminishing
access to maternity programs in rural and remote communities in Canada and recommends
policies to help ensure high-quality maternity care as close to home as possible.18
In this section of the report, estimates are presented of the time it takes for rural and urban
women to arrive at their hospital of birth. Next, the extent to which women residing in rural and
urban areas deliver in hospitals located in rural or urban areas is examined. The section
concludes with a description of the frequency of hospital transfers for rural and urban women.
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Figure 2: Percentage of Deliveries for Urban and Rural Women, by
Travel Time, Location of Hospital of Delivery and Hospital
Transfers, Selected Provinces/Territories, 2007–2008 to
2011–2012
A: Travel Time
B: Urban/Rural Hospital
C: Transfers
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
How Long Does It Take for Women to Reach Their Hospital of Birth?
Among 1,372,708 iii hospital deliveries between 2007–2008 and 2011–2012, 17.6%, or 241,162,
were for women who lived in rural areas. As shown in Figure 2, having a lengthy travel time to
deliver was a distinctly rural experience, with 40.5% of rural deliveries involving more than one
hour of travel to hospital, compared with less than 2% of deliveries for urban women. The
vast majority (90.0%) of urban women travelled 30 minutes or less to deliver. The mode of
transportation for women who experienced these prolonged travel times was quite variable
and included boat, plane, train or snowmobile in addition to travel by automobile or bus.
Across Canada, 17.2% of rural women travelled more than two hours to deliver. Lengthy travel
times were most pronounced in Canada’s territories—almost all (99.5%) rural women in Yukon
and the majority of rural women in Nunavut (84.1%) and the Northwest Territories (61.9%)
experienced this travel time. Across the provinces, rural women in Prince Edward Island were
least likely and those in Manitoba most likely to spend this much time travelling to the hospital of
their delivery (2.0% and 30.2%, respectively).
Figure 3 shows the proportion of rural women who travelled more than two hours for their delivery
during the five-year study period, by health region. In 10 health regions, more than half of women
had this lengthy travel time (see Box 3 for a list of these 10 health regions). In roughly two-thirds
of health regions included in the analysis (53 of 75), less than one in four rural women had to
travel more than two hours to deliver.
iii. Of the 1,374,127 deliveries included in this report, 1,419 deliveries were excluded from the travel time analysis because
information needed to calculate travel time was missing (for example, postal code).
10
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Figure 3: Percentage of Rural Women Travelling More Than Two Hours, by Health Region,
Selected Provinces/Territories, 2007–2008 to 2011–2012
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
11
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Vignette 2: Perspective of a Young Mother Who Travels to Give Birth
Susie, who is 22 years old, is from a remote community in the western (Kitikmeot) region of Nunavut, and is
expecting her third child. She lives with her parents and younger siblings, and most of her extended family
is nearby.
During her pregnancy, Susie has received prenatal care at the local Community Health Centre, where she’s been
seen by a midwife from the Kitikmeot Birthing Centre in Cambridge Bay. She’s developed a good relationship with
the midwife, and she’s very disappointed to learn that she will not be able to give birth at the centre because she
has developed hypertension and is considered high risk. Instead, she needs to fly to Yellowknife (900 km away)
about four weeks before the baby is due. Her medical travel and accommodation costs are covered by the Nunavut
Medical Travel Program, but because she is older than 18, the program will not pay for a companion to travel and
stay with her in Yellowknife.
The thought of going through childbirth alone is terrifying, and she wishes that her mother could come. The
problem is that her mom takes care of her frail grandmother. Her sister and cousin want to come with her, but they
both have children to look after. In the end, a cousin looks after Susie’s two children while she’s away, and she
goes to Yellowknife alone in January, after a snowmobile ride to the local airstrip.
Susie stays at the government-run Larga Kitikmeot Boarding Home, and it’s some relief to learn that the boarding
home has an interpreter and a driver to take her to her appointments. However, she’s worried about expenses that
are not covered by the Medical Travel Program.
It is very stressful for her to be away from her large extended family—she doesn’t know anyone in Yellowknife.
Staying in touch with her family and friends is a challenge but, thanks to the internet, Susie can communicate with
them using Skype and Facebook.
After three weeks, Susie goes into labour and gives birth to a baby girl. Her baby is jaundiced, which means that
she has to stay in Yellowknife an extra three days before being able to go home. The time away from her other
children seems endless.
Susie’s boyfriend, family and friends meet her at the airstrip upon her arrival home. She’s happy to see her
boyfriend, show off her baby and catch up on what happened while she was away. After such a long absence, it
takes a while to readjust to her routine, but fortunately her family and friends are a big help.
12
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Box 3: “Hot Spots” for Lengthy Travel Time to Delivery
In 10 health regions, the majority of rural women travelled more than two hours to deliver (shown in Figure 3).
These women accounted for 42% of the 41,408 women who travelled two or more hours to hospital for delivery.
Table 1: Health Regions Where the Majority of Women Travelled More
Than Two Hours to Deliver
Health Region
Percentage of Rural Women
Travelling More Than Two Hours
1. Yukon
99.5
2. Athabasca, Sask.
96.8
3. Burntwood, Man.
90.7
4. Keewatin Yatthé, Sask.
89.5
5. Nunavut
84.1
6. Mamawetan Churchill River, Sask.
63.8
7. North Vancouver Island, B.C.
62.5
8. Northwest Territories
61.9
9. North West, Ont.
57.2
10. NOR-MAN, Man.
51.1
Notes
The Burntwood and NOR-MAN health regions in Manitoba merged in May 2012.
See the supplementary tables for provincial/territorial/regional analyses.
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
A provincial-/territorial-funded medical travel benefit is available to eligible residents who may not be covered
through an employer or other federal program (such as the Non-Insured Health Benefits for First Nations and Inuit).
Common areas of coverage for medical travel include transportation to the nearest appropriate health professional
or facility for health services. Non-medical escorts are covered when specific criteria are met. Coverage of
accommodation, return travel and meals varies by jurisdiction.
There are relatively few pan-Canadian published studies with which to compare these results.
The Canadian Maternity Experiences Survey asked women how far they had to travel to deliver
their baby. In 2006–2007, 23% of women from Yukon and 40% of women from the Northwest
Territories said that they had to travel more than 100 km to give birth.19, iv In Manitoba, factors
associated with lengthy travel times (more than 113.8 km) to give birth between 2007–2008 and
2008–2009 included younger age (24 and younger), residence in a lower-income
neighbourhood, lone parenthood and multiparity.20
iv. The survey excluded women living on First Nations reserves, many of which are located in geographically remote areas with
limited access to maternity care. This exclusion results in an underestimation of the proportion of women who travel to give birth.
13
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Are Women From Rural Areas Delivering in Urban or Rural Hospitals?
Delivering a baby in one’s community of residence has many advantages, medically,
psychologically, socially and culturally. However, the ability to deliver close to home is
determined largely by the geographic distribution of birthing facilities, the range of services
available within these facilities and the availability of staff with obstetric training within
communities. This section of the report describes where urban and rural women delivered
in terms of their hospital of birth’s urban or rural location.
During the study period, 438 acute care hospitals in Canada reported at least one live birth.
Of these, 231 (or 53%) were located in rural areas. Of the 75 health regions summarized,
18 (or 1 in 4) did not have a rural hospital during the study period. Among the 10 health regions
with the highest concentration of rural women travelling more than two hours, only Yukon did
not have a rural hospital where at least one live birth was delivered.
Among deliveries for rural women, roughly two-thirds (67.3%) occurred in urban hospitals
(Figure 2). The remaining one-third of deliveries, an estimated 15,870 per year, occurred in rural
hospitals. About one-fifth (21.3%) of the rural women who delivered in urban hospitals travelled
more than two hours for their delivery. The need to travel more than two hours for delivery among
rural women is largely accounted for by these women travelling to urban hospitals (that is, 83.5%
of all travel of more than two hours among rural women occurred for travel to urban hospitals).
How Often Do Rural Deliveries Involve a Transfer From One
Hospital to Another?
Women living in rural and remote communities with medical services to support low-risk
pregnancies may choose to deliver their baby locally, with the option of a transfer to a higher
level of care if necessary. If a complication arises during pregnancy or labour, such women can
be transferred to another hospital for delivery. In other cases, a pre-delivery transfer may be
needed for women who present for the first time to prenatal care with an urgent, complex
medical need.
Post-delivery transfers may occur when a woman elects to travel from her rural area of
residence to give birth in an urban hospital and is then transferred back to her community
following her delivery to convalesce closer to home. A post-delivery transfer may also occur if
a woman delivers her baby in her community hospital but either the woman or her baby then
requires specialized care elsewhere.
As shown in Figure 2, rural women were four times more likely than urban women to be
transferred from one hospital to another (2.5% versus 0.6%). However, across Canada, a
hospital transfer is not common; approximately 1,236 rural women and 1,467 urban women
were transferred annually.
14
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Women Who Deliver in Hospital
How Do Urban and Rural Women Differ by Age, Parity, Risk and
Socio-Economic Status?
A number of maternal characteristics are associated with less-favourable birth outcomes for
mothers and babies. Giving birth at a very young or older age is a well-documented risk factor.
Having an underlying medical condition such as diabetes or hypertension—or developing such
a condition during pregnancy—can complicate the pregnancy and compromise the health of the
mother and infant. Furthermore, mothers’ circumstances in terms of their neighbourhood’s
socio-economic status (as measured by education, employment and income) are also predictive
of perinatal outcomes. In this analysis, parity, defined as the number of previous live births a
woman has had, was also associated with outcomes. In this section of the report, the question
of whether rural women as a group can be distinguished from urban women on these
dimensions is explored.
The factors examined in this report were selected based on associations with maternal and
infant outcomes reported in the literature, as well as their availability in the DAD. It is important
to note that this is not an exhaustive list—other factors, such as smoking and nutrition, are also
associated with maternal and infant outcomes. These factors were not included in the current
analyses because they were not captured in the available data.
15
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Figure 4: Percentage of Deliveries for Urban and Rural Women, by Age Group, Parity, Diabetes
and Hypertension Prevalence and Material Deprivation, Selected Provinces/Territories,
2007–2008 to 2011–2012
A: Age Group
B: Parity
C: Diabetes
D: Hypertension
E: Material Deprivation
Notes
It is mandatory to report parity only in Ontario, Manitoba, Saskatchewan, Alberta, Yukon, the Northwest Territories and Nunavut.
Due to differential reporting, parity is not adjusted for in the analysis of outcomes presented later.
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
16
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Maternal Age
Giving birth at the extremes of the reproductive age span is associated with risks to both
mothers and babies.5, 21 Teens face an increased risk of delivering preterm and having a low
birth weight or SGA baby when compared with adult mothers.5 Factors contributing to these
poor outcomes include a disadvantaged social environment, biological immaturity, social
deprivation, inadequate prenatal care, physical and sexual abuse, drug use and smoking.5
The rate of live births has decreased among women age 15 to 19.22
Births to mothers at the end of the reproductive age span also pose risks. For example,
pregnant women age 35 and older are more likely than younger pregnant women to have preexisting hypertension and to develop hypertension and preeclampsia, a serious pregnancy
complication.23 They are also more likely to develop diabetes during their pregnancy, to
experience placenta previa (a complication in which the placenta is located low in the uterus
and may block the cervix), to be pregnant with multiples and to have a C-section delivery.5, 24–29
Poor infant health outcomes associated with births at advanced maternal age include preterm
births and low birth weight or SGA babies.25, 27 Although advanced maternal age is associated
with an increased risk of giving birth to a baby with a chromosomal abnormality, the widespread
use of prenatal screening for these and other birth defects may have resulted in fewer live births
of infants with congenital anomalies.30 Economic and social factors in Canada have contributed
to women delaying child-bearing, which has resulted in a shift in the age distribution of women
giving birth.21 The rate of live births has increased among women age 35 and older.22
The distribution of rural versus urban women giving birth at the extremes of the reproductive
age span was quite distinct and characterized by a shift to younger ages. As shown in Figure 4,
delivery as a teen was more than twice as likely for rural than urban women (8.7% versus
3.6%). Nunavut, where all deliveries were to rural women, had the highest share of hospital
deliveries for teens in Canada (22.2%); a delivery for a rural teen was much less likely in Yukon
(9.8%) and the Northwest Territories (12.1%). Across the provinces, deliveries for rural teens
ranged from 6.5% in Ontario to 12.1% in Manitoba. At the other end of the age spectrum,
delivery at advanced maternal age (35 and older) was almost half as likely for rural women than
for their urban counterparts (11.4% versus 20.7%). This pattern of reduced likelihood of delivery
at advanced maternal age among rural women was evident in all provinces and territories.
Parity
Grand multiparity, the previous delivery of five or more live births, has been linked to poor birth
outcomes; however, this association tends to disappear when characteristics of the mother and
her health care are taken into account (for example, her age, socio-economic status and levels
of prenatal care).31 Extreme multiparity (prior delivery of 10 or more live births) has been
associated with certain medical complications and placental pathologies.32 Parity has been
found to modify the effect of maternal age on preterm birth and SGA. Older nulliparous women
(those giving birth for the first time) face a higher risk of preterm birth and SGA than older
multiparous women (those with one or more previous live births).33
17
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Although they were more likely to be younger, rural women were somewhat less likely to
experience their first birth than urban women (37.4% versus 45.2%) and more than three times
more likely to deliver a fifth or higher birth (7.5% versus 2.3%) (Figure 4). Across the territories,
delivering a fifth or higher birth among rural women ranged from 5.5% in Yukon to 9.3% in the
Northwest Territories to 17.0% in Nunavut. Across the four provinces reporting parity, Ontario
had the lowest rate of rural women delivering a fifth or higher birth (4.5%), while Manitoba had
the highest rate (12.4%).
Risk Factors/Comorbidities
Diabetes
Women who have diabetes as a pre-existing condition or who develop it during pregnancy are
at increased risk of poor maternal and infant outcomes. Gestational diabetes (GDM) is defined
as high blood sugar (hyperglycemia) with onset or first recognition during pregnancy. Babies
born to mothers with GDM are at risk for being LGA, a condition that contributes to higher rates
of C-section deliveries.
Figure 5: Percentage of Deliveries for Urban and Rural Women With Diabetes
(Combined Rate of Type 1, Type 2 and Gestational), by Province/Territory,
2007–2008 to 2011–2012
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
18
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Diabetes appears to be somewhat less of a problem for rural women than urban women (4.2%
versus 6.2%) when assessed from a pan-Canadian perspective (Figure 4). By jurisdiction, the
prevalence of diabetes was higher among rural than urban women in Yukon and Manitoba, and
it was higher among urban than rural women in B.C., Alberta and Ontario (Figure 5). Urban/
rural differences in screening for or reporting diabetes on the hospital discharge record could
potentially account for some these observed differences. When diabetes was present, it was
most likely to be GDM (88.7%).
Hypertension
High blood pressure during pregnancy may
• Increase the risk of a low birth weight baby because of decreased blood flow to the placenta;
• Cause the placenta to prematurely separate from the uterus, which may deprive the baby of
oxygen and cause heavy maternal bleeding; and
• Lead to a preterm delivery (for example, when the delivery must be induced to avoid
medical complications).
Preeclampsia, a serious condition characterized by high blood pressure and protein in the urine
after 20 weeks of pregnancy can, if left untreated, lead to serious, even fatal, complications for
mother and baby.
The prevalence of hypertension, either as a pre-existing condition or when developed during
pregnancy, among deliveries for rural and urban women was similar (6.7% versus 6.1%) (Figure 4).
This pattern was seen for all provinces and territories except the Northwest Territories, where urban
women were 1.5 times more likely to have hypertension than rural women (5.7% versus 3.8%).
When hypertension was present, it was almost always gestational hypertension (87.2%).
Material Deprivation
The association between lower socio-economic status and less-favourable health and birth
outcomes has been well documented.34–37 For this report, a material deprivation index was
constructed based on the following three characteristics of the mother’s area of residence:38
• The proportion of the population age 15 and older without a high school diploma or equivalent.
• The employment-to-population ratio for the population age 15 and older.
• The average income of the population age 15 and older.
Neighbourhoods were ranked into quintiles. After adjusting for household size, neighbourhoods
assigned to quintile 1 represent the least-deprived neighbourhoods, while neighbourhoods
assigned to quintile 5 represent those that are most deprived.
19
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Figure 6: Percentage of Deliveries for Urban and Rural Women Living in the MostDeprived Quintile, by Province/Territory, 2007–2008 to 2011–2012
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
Women from rural areas who delivered in hospital were more than twice as likely as those from
urban areas to reside in neighbourhoods considered to be most deprived according to their levels
of education, employment and income (38.7% versus 16.0%, Figure 4). Relatively few women from
rural areas resided in the least-deprived neighbourhoods, compared with their urban counterparts
(5.4% versus 23.3%). As shown in Figure 6, there was substantial variation in material deprivation
across the provinces and territories. The percentage of deliveries for rural women living in the mostdeprived neighbourhoods ranged from 29.1% in Yukon to 49.7% in the Northwest Territories and
83.8% in Nunavut. In five jurisdictions, more than half of the population of rural women who delivered
were from the most-deprived neighbourhoods (Newfoundland and Labrador, Nova Scotia, New
Brunswick, Manitoba and Nunavut). B.C. had the lowest share of deliveries for rural women residing
in the most-deprived neighbourhoods, as well as the rural population that was most similar to their
urban counterparts in this quintile (21.0% versus 15.2% living in the most-deprived neighbourhoods).
20
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Mode of Delivery
Are Rural Women More Likely Than Their Urban Counterparts to Have
a Caesarean Section, Assisted or Spontaneous Vaginal Birth,
Induction or Multiple Birth?
The mode of delivery—spontaneous vaginal birth, assisted vaginal birth or C-section—and
steps taken to hasten or ensure the birth of the baby influence the risk of poor maternal and
birth outcomes. A multiple birth (the delivery of twins, triplets or a higher number of babies per
delivery) is also associated with adverse outcomes.
Spontaneous Vaginal Birth Versus Caesarean Section
More than one in five births in Canada are delivered by C-section—this rate has steadily
increased since the mid-1990s.5, 6, 16, 39 High rates of C-section births are concerning because
the procedure carries some risk to the mother and baby and is associated with increased health
care costs.16, 39, 40 Characteristics of women that place them at a greater risk of a C-section
include older maternal age and undergoing a first birth. Factors shown to influence the decision
to perform a C-section include fetal presentation (such as breech position), multiple births and
how often technologies such as electronic fetal monitoring and labour induction are used.17
Because of the potential risks associated with C-section deliveries, elective “on demand”
C-sections for non-medical indications have been discouraged by the Society of Obstetricians
and Gynaecologists of Canada (SOGC).41
For these analyses, no distinction was made between primary C-section—women who have
never delivered by C-section—and repeat C-section—women who have had a previous
C-section. Vaginal delivery following a previous C-section can usually be accomplished safely
if the appropriate clinical indications are met.42
Women from rural areas were less likely to have C-sections than women from urban areas
(25.6% versus 28.6%) and were more likely to have vaginal (spontaneous) births (65.8% versus
60.8%) (Figure 7). The rates of C-section for women in rural versus urban areas were similar for
all provinces and territories.
Among rural women who delivered by C-section, 70.3% received the surgery in an urban
hospital. In the territories, this ranged from 100% in Yukon to 49.2% in both the Northwest
Territories and Nunavut. Across the provinces with at least one rural hospital (all provinces
except P.E.I.), the range among rural women was from 44.4% in Newfoundland and Labrador
to 87.0% in Saskatchewan. All rural residents of P.E.I. who had a C-section had their surgery
in an urban hospital (P.E.I. did not have a rural hospital during the study period).
21
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Figure 7: Percentage of Deliveries for Urban and Rural Women, by
Mode of Delivery, Induction and Multiple Births, Selected
Provinces/Territories, 2007–2008 to 2011–2012
A: Mode of Delivery
B: Induction
C: Multiple Births
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
22
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Assisted Vaginal Birth
Obstetric forceps and vacuum extractors can be used to assist in vaginal deliveries where
non-reassuring fetal status and inadequate progress during labour is observed. In many
countries, the rate of instrument-assisted deliveries is low, and forceps use in particular
appears to be declining.5, 39
Vaginal deliveries for women from rural areas were somewhat less likely to be assisted than
those for urban women (8.6% versus 10.6%) (Figure 7). There was little variation in assisted
vaginal births by jurisdiction or by urban or rural hospital of birth.
Induction
When labour does not begin spontaneously, clinicians may recommend artificially starting
the process by inducing labour. Induction may be necessary, for example, when babies are
overdue, if the mother or the fetus has medical issues or when the mother’s water breaks
too early.16 Guidelines issued by the SOGC recommend that women with an uncomplicated
pregnancy be offered induction at 41 to 42 weeks, given evidence that in such cases there is
a decrease in perinatal mortality without an increased risk of C-section.43
As shown in Figure 7, induction was used in just less than one in four births in Canada, with
little difference seen among women living in rural versus urban areas (24.1% versus 22.5%).
This pattern was consistently seen across the provinces and territories.
In some rural areas, higher rates of induction have been attributed to the desire or the need to
plan the date and location of birth for mothers in remote areas.44 A study of induction rates for
women living in rural B.C. found induction to be 1.3 times more likely for those needing to travel
outside of their hospital’s local health area.45 Women who have travelled from rural and remote
areas to a referral community and are awaiting the onset of labour may elect induction when it
is offered to reduce time away from home.46, 47 In our cohort, induction rates for rural first-time
mothers who travelled more than two hours were similar to those travelling an hour or less
(24.3% versus 25.3%). However, induction rates for deliveries for mothers with previous live
births (who are presumed to have other children at home) were higher among those who
travelled more than two hours (22.7%) compared with those travelling an hour or less (18.5%).
Among rural women who were induced during their hospital stay, 73.1% delivered in an urban
hospital. Rural women delivering in an urban hospital were 1.3 times more likely to be induced
than those delivering in a rural hospital (26.2% versus 19.8%).
Multiple Births
An increase in the use of medical interventions to enhance fertility and the shift toward older
mothers giving birth has contributed to rising rates of multiple births.5 Women carrying multiple
pregnancies are at increased risk of anemia, preeclampsia, preterm labour and C-section.5
Multiple-birth infants are at higher risk of having low birth weight, poor fetal growth, preterm birth
and perinatal death.
23
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Fewer multiple births are expected in rural areas, given the younger ages at which mothers in
rural areas have their babies. Multiple births were relatively rare, occurring in 1% to 2% of all
deliveries. Multiple-birth deliveries for mothers from rural and urban areas were essentially
identical (1.5% versus 1.7%) (Figure 7).
Providers
This section of the report first discusses the role of various obstetric health care providers—
obstetricians/gynecologists (OB/GYNs), family physicians (FPs) and midwives—and then
describes how the providers of intrapartum v care vary in deliveries for urban and rural women.
In addition, data is provided on trends in the role of FPs in the delivery of Canadian obstetric care.
How Do Urban and Rural Women’s Providers of Intrapartum
Care Differ?
A diverse set of practitioners assist women before, during and/or after childbirth. Among those
who provide deliveries within hospitals are OB/GYNs, FPs and midwives. This section of the
report profiles the health professionals who cared for Canada’s mothers and their newborns
during their hospital stay for a delivery: their numbers, their distribution, trends in their practices
and the services they provide.
Obstetricians/Gynecologists
Women, especially those with a high-risk pregnancy, may receive maternity care from an
OB/GYN specialist. Obstetricians in Canada attend more than 80% of births, according to a
2008 SOGC report.48 Of the 1,650 OB/GYNs in Canada, 1,050 provided intrapartum care.48
Family Physicians vi
Many mothers in Canada receive care from FPs throughout their pregnancy, from the prenatal
to postnatal periods. The 35,000 FPs in Canada in 2010 accounted for just more than half (51%)
of all physicians in the country.21 FPs can be involved in all stages of maternity and infant care—
from preconception to prenatal to postpartum and beyond. Some FPs receive special surgical
training so that they can perform C-sections.18 Others may receive training in anesthesia so that
they can provide epidurals administered during labour, anesthesia at C-section and neonatal
resuscitation. Only 10.5% of FPs reported involvement in intrapartum care in the 2010 National
Physician Survey, a drop from 17% in 2001.48, 49 FPs in rural areas were twice as likely to offer
intrapartum care in 2010 as their urban counterparts (16% versus 8%).49
v. “Intrapartum” refers to the time period spanning labour and delivery.
vi. Throughout this report, references to family physicians include both physicians practising family medicine and those practising
general medicine. The term “family physician” has been used in recognition of the fact that, in Canada, family physicians and not
general practitioners are most likely to provide maternity and infant care.
24
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Midwives
Midwives are primary health care providers for women; they provide care from the prenatal
phase of pregnancy to six weeks postpartum. Most provinces and territories have regulated
midwifery. This means that midwives practising in these jurisdictions must have formal training
and be licensed to practise. Regulation does not necessarily mean that a jurisdiction publicly
funds care provided by midwives. Jurisdictions may also differ in the settings in which they allow
midwifery to be practised (for example, home, hospital or birthing centre).17, 50 As of 2010, there
were almost 900 midwives working in Canada and 100 students admitted annually to university
midwifery programs.51 Midwives have been instrumental in offering maternity care in birthing
centres serving remote Aboriginal communities.
A birth may be attended by a single provider or by several different types of providers,
depending on the nature of the birth, its complexity and its duration. In the following section,
data is provided on the providers recorded on the hospital discharge record as being directly
involved in care during the hospital stay.
Figure 8: Percentage of Deliveries for Urban and Rural Women, by Type of Provider
Attending, Selected Provinces/Territories, 2007–2008 to 2011–2012
Notes
FP: family physician.
OB/GYN: obstetrician/gynecologist.
Attending provider types sum to greater than 100.0% because a delivery may be attended by more than one type of provider.
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
25
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
As shown in Figure 8, deliveries for rural women were more likely than those for urban women
to be attended by an FP (44.8% versus 26.0%) and less likely to be attended by an OB/GYN
(57.7% versus 79.1%) or midwife (4.0% versus 5.7%). Most deliveries for rural women in the
territories were attended by an FP (Yukon, 90.7%; the Northwest Territories, 85.5%; Nunavut,
68.1%). Across the provinces, the attendance of rural women’s births by an FP ranged from
23.7% in Newfoundland and Labrador to 64.3% in B.C.
Compared with rural women who delivered in an urban hospital, rural women who delivered in
a rural hospital were 2.7 times more likely to have their delivery attended by an FP (78.3%
versus 28.6%) and 0.2 times as likely to have their delivery attended by an OB/GYN (17.8%
versus 77.1%).
Figure 9: Percentage of Deliveries for Urban and Rural Women, by Caesarean Section
Provider, Selected Provinces/Territories, 2007–2008 to 2011–2012
Notes
FP: family physician.
OB/GYN: obstetrician/gynecologist.
C-section provider types are mutually exclusive but sum to less than 100.0% because a small percentage of C-sections were
missing provider information.
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
As C-sections involve additional resources and specialized personnel, they are provided in only
a subset of hospitals. Of all C-section deliveries, 16.1% (a total of 62,046 deliveries) were
performed for rural women. As shown in Figure 9, virtually all (97.7%) C-sections among urban
women were attended by OB/GYNs. In contrast, 75.8% of C-sections among rural women were
attended by OB/GYNs. The balance of C-sections among rural women was attended by FPs
(15.3%) or general surgeons (6.6%). Among deliveries for rural women, the share of C-sections
26
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
attended by an FP or a general surgeon ranged from 52.1% in Nunavut to 39.0% in the
Northwest Territories to 0% in Yukon. Across the provinces, this ranged from less than 1% in
P.E.I. and Nova Scotia to 40.6% in Alberta.
Compared with rural women delivering in an urban hospital, rural women delivering in a rural
hospital were 12.1 times more likely to have their C-section attended by an FP or a general
surgeon (61.6% versus 5.1%). C-sections among rural women in rural hospitals accounted
for 83.7% of all C-sections among rural women attended by FPs or general surgeons.
Vignette 3: Perspective of a Rural Family Physician
Jim is a family physician who grew up in a small community; he has spent the last 30 years practising medicine
in rural communities. The first community he practised in was a challenge—the two other physicians in the
community did not work well together and he did not feel supported by them. He also found that being on call for
emergencies every third day and covering all calls for his own obstetric patients was hard on his family. There were
no surgical services available in the community; consequently, women with high-risk pregnancies were transferred
to a larger regional hospital. In addition, a decline in the resource sector created instability in the community and
the local hospital had difficulty retaining staff.
Despite this situation, Jim found that he enjoyed providing a full range of services, including obstetrics, in a rural
setting, so he decided to leave to pursue additional training to expand his practice. He completed a year of
additional training with the obstetrics department in a large centre, which allowed him to deal with more difficult
cases and subsequently move to a larger community where surgical services were available. He is now able to
perform C-sections and provide anesthesia services, including epidurals. The five family physicians in the
community have a group practice and a shared call model that includes obstetric coverage. This allows Jim to be
on call only once a week during the week and every fifth weekend. The physicians and hospital staff work well
together. The health region provides opportunities for ongoing education, and the local hospital and physicians
have a good relationship with the obstetricians and staff at the larger regional hospital.
Jim’s additional training and relocation allowed him to fulfill his career aspirations and spend more time with his
family. However, his decision to leave the small community where he formerly practised left the remaining, alreadyoverburdened physicians with additional responsibilities. Following Jim’s departure, pregnant women in the
community found it difficult to access timely prenatal care from the remaining two family physicians, who continued
to struggle to serve the medical needs of their community.
Trends in the Type of Caregiver Providing Labour and Delivery Care
and the Number of Services Provided
To gauge the extent to which FPs are participating in obstetric care, and the intensity of that
care, analyses were conducted using the National Physician Database (NPDB). The NPDB
contains data on physicians’ fee-for-service (FFS) claims provided to CIHI by provincial/
territorial medical service plan administrative systems. NPDB files contain, for each physician
within each jurisdiction, the total number of clinical services provided and payments made for
each fee service code billed. All fee service codes within the NPDB are mapped to 1 of 120
National Grouping System (NGS) categories. NGS categories are further classified under 14
27
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
broad clinical service areas, one of them being obstetric services. These obstetric services
include delivery, services at time of delivery (such as repairing lacerations and removing a
retained placenta) and other obstetric services (such as doing a stress test and fetoscopy).
As shown in Figure 10, there was a steady decrease in FP participation in obstetrics from 1992
to 2009, combined with an increase in the average number of services provided by those family
doctors who continued to provide care. While the trend in FP participation was consistent across
provinces (Table 2), the trend in the number of services varied across jurisdictions (Table 3).
Figure 10: Trends in Family Physician Participation in Obstetric Care, Selected
Provinces/Territories, 1992–1993 to 2009–2010
Notes
For this analysis, 2002–2003 and 2003–2004 were previous to the years studied; as such, this data was not requested from the
NPDB. The data for 1992–1993 to 2001–2002 presented here was taken from a previous report.52
Source
National Physician Database, 1994–1995 to 2009–2010, Canadian Institute for Health Information.
28
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Table 2: Trends in Family Physician Participation Rate (Percentage) in Obstetric Care,
by Province, 1994–1995 to 2009–2010
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
B.C.
49
46
41
40
36
33
30
27
25
22
21
20
19
18
19
18
Alta.
36
35
34
33
32
31
28
27
25
24
23
21
21
20
18
18
Sask.
48
47
45
41
39
38
33
31
30
25
26
24
23
23
25
21
Man.
27
26
25
24
22
21
22
23
23
23
22
20
19
18
17
17
Ont.
19
19
17
16
14
13
13
12
11
10
9
9
9
9
8
8
N.B.
29
27
27
25
23
21
19
19
16
14
13
13
12
11
10
8
N.S.
41
37
34
31
29
27
25
22
21
18
17
16
14
14
13
13
N.L.
26
24
21
21
20
16
17
12
10
9
6
6
6
5
4
4
Can.
26
25
23
22
20
19
17
16
—
14
15
15
14
13
13
12
Note
— Data not available.
Source
National Physician Database, 1994–1995 to 2009–2010, Canadian Institute for Health Information.
Table 3: Average Number of Services Provided by Family Physicians Involved in Obstetric Care,
by Province, 1994–1995 to 2009–2010
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
B.C.
18
18
19
19
20
21
21
23
25
27
36
38
39
42
44
43
Alta.
32
33
33
35
40
42
44
46
53
55
60
70
78
85
95
96
Sask.
22
22
23
24
23
21
21
21
20
21
19
21
22
23
23
26
Man.
27
27
29
29
27
25
27
25
28
27
28
34
35
35
38
40
Ont.
25
26
27
26
26
27
25
26
27
28
30
29
28
31
31
31
N.B.
23
25
24
23
25
23
23
20
24
25
24
24
26
28
29
34
N.S.
19
21
23
23
24
25
23
25
23
26
26
26
29
33
33
33
N.L.
27
31
30
30
21
30
21
24
24
24
21
20
20
19
22
24
Can.
29
29
31
31
33
34
34
36
—
—
36
39
41
45
47
49
Note
— Data not available.
Source
National Physician Database, 1994–1995 to 2009–2010, Canadian Institute for Health Information.
With the NPDB, we can calculate the percentage of family doctors that provides obstetric care
and the average number of services they provide. The NPDB, however, does not provide a
comprehensive view. In 2003, an estimated 19.5% of total clinical payments for all physicians
were made through alternative payment plans (non-FFS); examples include capitation, salary
and hourly wages. The NPDB also cannot be used to distinguish between FPs who practise in
urban and rural areas.
29
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Maternal and Infant Outcomes
As the number of rural hospitals and maternity services has declined, questions have been
raised and concerns expressed about the implications of resource policies for pregnant rural
mothers and their babies.53 While answers to these questions cannot be fully answered with
available data, this section of the report provides some insights and examines two maternal
health outcomes: severe maternal morbidity and unplanned maternal readmissions. In addition,
analyses of three infant outcomes are presented: preterm live births, and live births that are
either SGA or LGA. First, multivariate analyses of differences between urban and rural maternal
and infant outcomes are presented that control for the underlying differences between mothers
from urban and rural areas. Next, unadjusted rates for these outcomes are presented for rural
women by health region. Separate analyses are then presented to examine the relationship
between rural women’s travel time to hospital of birth and outcomes. Finally, rural women’s
delivery outcomes are compared according to whether the delivery occurred in an urban or
rural hospital. Many outcomes of interest were either not available on hospital discharge
records (such as psychosocial and family outcomes) or were not comprehensively captured
(for example, maternal and perinatal mortality).
How Do Outcomes Compare for Urban and Rural Women?
Given the marked differences in demographic and health characteristics of urban and rural
women, several maternal characteristics are controlled for in the following multivariate analyses
of maternal and infant outcomes: age, hypertension, diabetes, mode of delivery, induction,
plurality (singleton versus multiple birth) and material deprivation. Odds ratios adjusted for these
factors are used to interpret these findings (Box 4). Adjusted odds ratios and associated
confidence intervals for all factors included in the analysis are presented in the appendix.
Box 4: Interpreting Odds Ratios
The odds ratio (OR) evaluates whether the odds of a certain event or outcome are the same for two groups.
Odds are the probability of an event occurring divided by the probability of the event not occurring. An OR is the
odds of the event in one group (for example, rural women) divided by the odds in another group (for example,
urban women).
Interpreting ORs
• An OR of 1 indicates that the condition or event under study is equally likely to occur in both groups.
• An OR greater than 1 indicates that the condition or event is more likely to occur in the first group.
• An OR less than 1 indicates that the condition or event is less likely to occur in the first group.
Statistical significance of an OR is identified when its associated confidence interval (CI) does not overlap with 1.
Statistically significant differences do not always indicate clinically meaningful differences.
30
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Figure 11: Adjusted Odds Ratios for Deliveries for Rural Versus Urban Women,
Maternal and Infant Outcomes, Selected Provinces/Territories, 2007–2008
to 2011–2012
Notes
SMM: severe maternal morbidity.
SGA: small for gestational age.
LGA: large for gestational age.
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
Severe Maternal Morbidity
A number of conditions threaten the life and well-being of mothers during and after labour.
Interest in monitoring maternal morbidity has heightened, as changes in the characteristics of
mothers and births—such as advancing age of mothers; higher prevalence of obesity; and
changes in obstetric practice, such as increased use of epidural anesthesia, labour induction
and C-section—have contributed to an increased risk of these conditions and cumulatively add
to the risk of maternal morbidity. A composite measure, severe maternal morbidity, has been
developed to capture the occurrence of any of a number of serious conditions related to
pregnancy (Box 5).1 This measure is useful in surveillance of the quality of maternity care, more
so than maternal mortality, because maternal mortality rates have declined to such an extent
that they are too low to reliably present.
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Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Box 5: Examples of Conditions Included in the Measure of Severe
Maternal Morbidity1
• Cardiac arrest, cardiac failure or
myocardial infarction
• Postpartum hemorrhage and blood transfusion
• Complications of anesthesia (pulmonary, cardiac,
central nervous system)
• Puerperal sepsis
• Death, obstetric cause
• Eclampsia
• Hemorrhage and coagulation defect
• Postpartum hemorrhage and hysterectomy
• Repair of bladder, urethra or intestine
• Rupture of uterus before or during labour
• Septicemia during labour
• Obstetric shock
• Obstetric embolism
As illustrated in Figure 11, deliveries for rural women were more likely than those for urban
women to involve severe maternal morbidity (2.4% versus 1.7%; OR 1.4; 95% CI 1.3 to 1.4).
Factors that significantly increased the odds of severe maternal morbidity included C-section
delivery, having both diabetes and hypertension, having hypertension alone (either pre-existing
or gestational) and multiple birth (see the appendix). This increased likelihood means that,
relative to deliveries for urban women, an additional 1 of every 151 deliveries for rural women
would have been expected to have severe maternal morbidity over the study period.
Unplanned Maternal Readmissions
An unplanned maternal readmission is an unplanned admission (for all causes, excluding
hospital transfers) to an acute care hospital within 30 days of being discharged after a delivery.
Because such readmissions often occur following serious complications related to childbirth,
they are studied to better understand the causes of serious postpartum complications, improve
care delivery and outcomes, and prevent potentially avoidable hospitalizations.5 Women with a
C-section birth and those with a forceps- or vacuum-assisted birth are more likely to be
readmitted to hospital than women who had a vaginal delivery.54 The most common reason for
readmission among women who have had a C-section is infection of an obstetric surgical
wound,54 whereas postpartum hemorrhage is more often the cause for readmission among
women following vaginal delivery.5
As shown in Figure 11, women with a rural residence had increased odds of hospital readmission
(1.4% versus 1.2%; OR 1.2; 95% CI 1.1 to 1.2). Factors that increased the odds of an unplanned
maternal readmission to hospital included having diabetes or hypertension (or both conditions)
and having had a C-section, assisted birth, induction or multiple birth. Deliveries for teen mothers
(younger than age 20) also had a small but significant effect on the odds of readmission (see
the appendix). This increased likelihood means that, relative to deliveries for urban women,
an additional 1 of every 423 deliveries for rural women would have been expected to have
an unplanned readmission over the study period.
32
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Infant Morbidity
Preterm Births
Babies who are born before 37 completed weeks of gestation are considered preterm (see Box 6
on the derivation of gestational age).55 Preterm births are an important public health concern, as
they are the leading cause of infant mortality in economically developed countries and account for
about three out of four deaths that occur in the perinatal period (from about five months before to
one week after birth).56, 57 Preterm births also contribute to both short- and long-term morbidity
and are associated with considerable health care costs.58–60 Given that the last several weeks of
normal gestation are responsible for more than one-third (35%) of brain growth,61 as well as
significant lung and general fetal development,62 it is not uncommon for preterm babies to have
increased rates of respiratory distress, temperature instability, hospital readmission and neurocognitive problems, compared with full-term infants.60 Moreover, certain health issues—such as
cerebral palsy, psychiatric illness and attention disorders—often extend into adulthood.60, 63
Box 6: How Is Gestational Age Derived?
Gestational age may be calculated using the first day of the mother’s last menstrual period (LMP) or by using
early ultrasound measurements. Ultrasound-based estimates are considered more precise than estimates based
on LMP.3, 4
In the DAD, gestational age is recorded in completed weeks and is derived from medical charts—this represents
the best clinical estimate of gestation and includes both ultrasound- and LMP-based estimates.
There are many reasons why a baby might be born preterm. Preterm births may be medically
indicated or spontaneous. In cases where continuing a pregnancy would lead to serious maternal
or fetal risk—about 30% of preterm births fall into this category—a medically indicated preterm
delivery by C-section or induction is performed to improve obstetric outcomes.64 Complications
such as hypertensive disorders, maternal bleeding, intrauterine growth restriction and fetal
distress3 are among the most common reasons for medically indicated preterm deliveries.
Spontaneous preterm births—the other 70% of preterm births fall into this category—may also
be caused by fetal distress or poor intrauterine growth.65 Some of the factors that have been
associated with preterm births include low socio-economic status, rural place of residence,
younger and older maternal age, multiple births, high or low parity, history of preterm delivery
and maternal medical conditions such as hypertension and diabetes.65–69 These factors are
examined in this report, as this data is available in CIHI’s databases. Other factors that can also
contribute to preterm births, but that were not included in our analyses, include maternal
race/ethnicity, physical and psychological stress, genitourinary infections, placental disorders,
substance use and poor prenatal care.65, 67, 70
33
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
In North America, preterm birth rates have increased over the last few decades. Several factors,
such as delayed child-bearing and the use of assisted reproductive technologies, have contributed
to the increase in multiple births and preterm deliveries. Increases in obstetric interventions (that is,
those linked to medically indicated preterm births) have substantially contributed to the increase.3, 71
In Canada, the preterm birth rate steadily increased from approximately 6% in the early 1980s71
to 8% in more recent years.72
As shown in Figure 11, a woman’s rural residence caused a small but significant reduction in
the odds of a preterm birth (7.6% versus 8.1%; OR 0.9; 95% CI 0.9 to 1.0). Factors that
significantly increased the odds of a preterm birth included multiple birth and having diabetes
and hypertension (see the appendix). This decreased likelihood means that, relative to births
for urban women, 1 less preterm birth would have been expected for every 133 births for rural
women over the study period.
Small for Gestational Age
Fetal growth restriction is the failure to attain optimal fetal growth. The use of SGA as an
indicator of neonatal outcome was proposed several decades ago as a measure of fetal growth
restriction, largely due to difficulties estimating intrauterine growth.73, 74 An SGA birth refers to a
newborn with a birth weight lower than an expected normative threshold, or cut-off, for a given
gestational age and sex6 (Box 7).
Box 7: Small and Large for Gestational Age
The methodology used to identify SGA and LGA births in our study is limited to singleton and twin births only. SGA
and LGA were calculated using the study cohort, rather than a standard growth curve.2
In this study, SGA and LGA births were defined using birth weight percentile by gestational age and sex for all
Canadian live births included in this analysis between 2007–2008 and 2011–2012. The rates were limited to
singleton births of known birth weight and sex with a gestational age between 22 and 42 weeks and to twin births
of known birth weight and sex with a gestational age between 22 and 40 weeks.
SGA means that the fetus or newborn is smaller in size than normal for the baby’s sex and gestational age,
measured as newborns with birth weight less than the 10th percentile cut-off specific to that gestational age and sex.
LGA means that the fetus or newborn is larger in size than normal for the baby’s sex and gestational age, measured
as newborns with birth weight greater than the 90th percentile cut-off specific to that gestational age and sex.
Babies born to rural women were significantly less likely than urban newborns to be SGA
(8.2% versus 10.3%; OR 0.7; 95% CI 0.7 to 0.7) (Figure 11). These findings from 2007–2008
to 2011–2012 are consistent with those from 2006–2007, where the SGA rate was significantly
lower among rural than urban women (7.0% versus 8.7%).55 This decreased likelihood means
that, relative to births for urban women, 1 less SGA birth would have been expected for every
35 births for rural women over the study period.
34
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
SGA births were more likely when the mother had hypertension (either pre-existing or
gestational) and had an assisted or induced delivery. Babies born to women with diabetes
(either pre-existing or gestational) were significantly less likely to be SGA. An income gradient
existed so that babies born to women living in higher-income neighbourhoods were significantly
less likely to be SGA (see the appendix).
Large for Gestational Age
Babies that are large given their gestational age are a concern because they can contribute to a
difficult or prolonged labour and increase the risk of a C-section delivery. Maternal diabetes is
the most common cause of LGA. Excessive weight gain during pregnancy may also contribute
to LGA.
Deliveries for rural women were somewhat more likely to result in LGA births than those for
urban women (12.5% versus 9.4%; OR 1.4; 95% CI 1.4 to 1.4) (Figure 11). Diabetes is the
principal factor that significantly increases the odds of LGA. C-section was also associated with
LGA in these analyses (see the appendix). This increased likelihood means that, relative to
births for urban women, an additional 1 of every 30 births for rural women would have been
expected to be LGA over the study period.
How Do Outcomes for Rural Women Vary Across Canada’s
Health Regions?
The following section discusses variations in maternal and infant outcomes by health region,
focusing solely on rural women.
Severe Maternal Morbidity
Figure 12 shows considerable variation in the unadjusted rate of severe maternal morbidity
among deliveries for rural women across Canada’s health regions. There is no consistent
pattern; however, several regions in Saskatchewan and Newfoundland and Labrador and all the
regions in Alberta exhibited higher rates, while several regions in Ontario, Manitoba, B.C. and
Nova Scotia had lower rates. Deliveries for rural women from the Northwest Territories had a
lower rate of severe maternal morbidity.
35
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Figure 12: Percentage of Deliveries for Rural Women Having Severe Maternal Morbidity,
by Health Region, 2007–2008 to 2011–2012
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
36
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
When severe maternal morbidity was assessed from 2003 to 2007, investigators found the
overall rate to be 13.8 per 1,000 deliveries in Canada. Five provinces or territories had rates that
were significantly higher than those in the rest of the country (Newfoundland and Labrador,
Saskatchewan, Alberta, the Northwest Territories and Nunavut).75 The results presented in
Figure 12 are restricted to deliveries to rural women, which are not directly comparable with
those of the earlier study.
Unplanned Maternal Readmissions
Figure 13 shows variation in unadjusted rates of unplanned readmissions by health region for
deliveries among rural women across Canada. The majority of regions in Ontario had lower
rates of readmissions; the North West region was the only region with a higher rate in Ontario.
The majority of regions in Manitoba and several regions in Saskatchewan had higher rates
of readmission.
Maternal readmission rates have been shown to vary significantly among provinces and
territories, both for women with C-section delivery and for those with vaginal delivery.5, 75 These
regional differences may be due, in part, to variations in length of stay prior to hospital discharge
(following childbirth), admission policies or variations in availability of outpatient and other
community-based services.5
37
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Figure 13: Percentage of Deliveries for Rural Women With Unplanned Maternal Readmission,
by Health Region, 2007–2008 to 2011–2012
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
38
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Preterm Births
There appears to be very little regional variation in preterm birth rates for rural women (Figure 14).
Of note, however, is that babies born to rural women from the Northwest Territories were less
likely, while babies from Nunavut were more likely, to experience a preterm birth. In the provinces,
11 regions had lower and 7 regions had higher rates of preterm birth. The regions with lower
rates were
• Western, Newfoundland and Labrador;
• South West Nova, Nova Scotia;
• Pictou County, Nova Scotia;
• Region 2, New Brunswick;
• Region 3, New Brunswick;
• Waterloo Wellington, Ontario;
• South Eastman, Manitoba;
• Central, Manitoba;
• Assiniboine, Manitoba;
• South Zone, Alberta; and
• Northwest, B.C.
The regions with higher rates were
• Hamilton Niagara Haldimand Brant, Ontario;
• South East, Ontario;
• Champlain, Ontario;
• North Eastman, Manitoba;
• Burntwood, Manitoba;
• Calgary Zone, Alberta; and
• North Vancouver Island, B.C.
39
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Figure 14: Percentage of Newborns Delivered by Rural Women Preterm, by Health Region,
2007–2008 to 2011–2012
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
40
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Small for Gestational Age
Figure 15 shows significant variation among rural newborns in rates of SGA across Canada’s
health regions. In the territories, Nunavut and the Northwest Territories had lower rates of SGA.
In the provinces, several regions in Nova Scotia, New Brunswick and Alberta had higher rates of
SGA. A pattern was observed in Ontario, Manitoba and Saskatchewan of regions exhibiting
lower rates of SGA.
Large for Gestational Age
There was considerable variation in LGA rates across regions (Figure 16). Among the
territories, the Northwest Territories had a higher rate of LGA. The majority of regions in
Manitoba and Saskatchewan exhibited higher rates, while all regions in Alberta and several
regions in Nova Scotia and New Brunswick had lower rates of LGA.
41
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Figure 15: Percentage of Newborns Delivered by Rural Women That Were Small for Gestational
Age, by Health Region, 2007–2008 to 2011–2012
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
42
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Figure 16: Percentage of Newborns Delivered by Rural Women That Were Large for Gestational
Age, by Health Region, 2007–2008 to 2011–2012
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
43
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Vignette 4: Perspective of a Mother From Rural Alberta
Christine lives in rural Alberta with her husband and three children. They have a mixed farming operation on 1,000
acres that includes cattle and a variety of grains. Christine is actively involved with the farming operation and is
expecting her fourth child at age 38. She had her first two children at a small hospital an hour away, but she had to
travel to Edmonton for her last birth because of bleeding that developed in her last trimester. She is hoping that she
will be able to deliver at her local hospital because she is due during harvest season. If she had to go to Edmonton
for an extended period, her husband would probably have to hire help. Fortunately, Christine’s sisters live nearby
and have offered to look after the children while she is in hospital, but she is not sure they could deal with them for
three or four weeks.
Christine is concerned that her age may make this pregnancy even riskier than her last one. The new doctor in
town, a family physician, has been reassuring and Christine is confident in his abilities. But if it seems likely that
she will need a C-section, Christine will have to make the four-hour trip to Edmonton in advance of the birth. And
with only one other doctor available locally, it is worrisome that either one might not be available in an emergency.
It has been difficult for her community to sustain its local hospital obstetric service. Her last doctor left to work
outside of Edmonton in a large group practice because she found the amount of on-call time difficult to balance
with her family life.
When Christine goes into labour two weeks before her due date, her family physician is available to assure her that
the labour looks completely normal and that she can remain at the local hospital. Her husband stays with her and
provides support during the labour and birth of their healthy baby boy. Her other children are brought to the hospital
by Christine’s sister, where they meet their newborn brother. After two days, Christine is able to return home to the
farm with her new baby.
Do Outcomes for Rural Women Vary by Time Travelled to Delivery?
There is evidence that travel to care is associated with poorer outcomes. For example, a study of
rural women in B.C. who had to travel for more than one hour to access the nearest maternity
service with C-section capability found relatively high rates of induced labour for logistical reasons
and more unplanned out-of-hospital deliveries.8 The birth outcomes of these rural mothers were
poor compared with those for mothers residing in urban areas. There were higher rates of perinatal
mortality and, among live births, a greater number of days spent in a neonatal intensive care unit.
Figure 17 shows unadjusted rates for the five outcomes included in this report and suggests that,
for all but LGA and preterm births, there does not appear to be a strong relationship between
travel time for rural women’s deliveries and outcomes. For LGA, there is an increase in the rural
rate when travel time exceeds two hours (15.8%). The increase in the rate of preterm births with
travel time may reflect the ability to screen for or recognize risk factors for preterm birth (such
as bleeding) and then recommend that women travel from their community to a hospital offering
services that may be needed. It could also indicate that lengthy travel times to delivery are a
risk to pregnancies. The data available for this report cannot distinguish between these potential
explanations.
44
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
When comparing rural deliveries that occurred in hospitals close to home (travel time within 30
minutes) and urban deliveries, it was noted that the rate of unplanned maternal readmissions was
similar (1.2% in both cases). However, the SGA rate was lower for rural deliveries close to home
(8.2%) than for urban deliveries (10.3%).
Figure 17: Rates for Maternal and Infant Outcomes by Travel Time for Rural Deliveries,
Selected Provinces/Territories, 2007–2008 to 2011–2012
Notes
SMM: severe maternal morbidity.
SGA: small for gestational age.
LGA: large for gestational age.
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
Lengthy travel to give birth also poses both practical and emotional hardships. The need to take
time off from work with the attendant loss of income and the expenses associated with travel
and accommodation may take a financial toll. And being far away from family and friends may
be very stressful and isolating for mothers at a time when they are in need of social support.
Among the women responding to the Maternity Experiences Survey who had travelled to
another city, town or community to give birth, “very negative” ratings of the experience of
travelling to give birth were reported by 14% of women who travelled more than 100 km. This
is in contrast to only 2% of women who travelled 100 km or less to give birth. A survey of B.C.
women who had given birth found that those who had to travel more than one hour to access
maternity services were seven times more likely to experience moderate or severe stress than
women who had local access to maternity services.76
45
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Do Outcomes for Rural Women Vary by Urban Versus Rural
Hospital of Birth?
Rural women who delivered in an urban hospital had higher rates of preterm birth than their
counterparts who delivered in rural hospitals (9.7% versus 3.1%) (Figure 18). This finding could
be explained if rural women who experienced premature labour or another complication were
transferred from their rural community to an urban centre for delivery. Other birth outcomes
occurred with similar frequency when births took place in either an urban or rural hospital.
Figure 18: Maternal and Infant Outcomes for Rural Women, by Urban or Rural Hospital
of Delivery, Selected Provinces/Territories, 2007–2008 to 2011–2012
Notes
LGA: large for gestational age.
SGA: small for gestational age.
SMM: severe maternal morbidity.
Source
Discharge Abstract Database, 2007–2008 to 2011–2012, Canadian Institute for Health Information.
46
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Conclusion
Women giving birth in Canada’s hospitals are geographically widely dispersed, with 18%
residing in rural and remote areas. A major finding of this report is that women from rural areas
have higher odds of severe maternal morbidity, hospital readmission and LGA infants than
women from urban areas, after controlling for differences in their socio-economic profiles and
delivery characteristics. Roughly two-thirds of women from rural areas commuted to urban
hospitals to have their babies. For one in six rural women, reaching their hospital to deliver
involved travelling more than two hours. These lengthy travel times were associated with higher
rates of preterm births. The rate of preterm birth among rural women was also elevated when
deliveries occurred in urban rather than rural hospitals. These findings could possibly reflect
effective triaging of high-risk pregnancies from rural areas to distant hospitals staffed with
specialists and advanced technology. Unfortunately, the administrative data upon which this
report is based is inadequate to explain these associations. The evidence does suggest that the
system for caring for rural pregnant women and their newborns is working, or is successful in
achieving positive birth outcomes for women from both rural and urban areas.
While the results in aggregate are reassuring, the report provides evidence of significant
variation in maternal and infant outcomes across the study’s 75 health regions. Health
administrators face considerable challenges as they design systems of obstetric and neonatal
care that will accommodate the needs of rural and remote communities. Examining health
outcomes at the level of the health region can assist health planners as they consider policies
related to clinical practice, personnel, infrastructure, transportation, triage and other issues that
affect access to delivery services and birth outcomes. Many factors contribute to variations in
maternal and infant outcomes by jurisdiction; this analysis had access to just a few of these
factors. Focused investigation at the local level is needed to better understand why a
jurisdiction’s value on a particular outcome differs significantly from the pan-Canadian value.
47
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Appendix: Odds Ratios and Associated
Confidence Intervals for Maternal and
Newborn Outcomes
Table A.1: Odds Ratios and Associated Confidence Intervals for Maternal Outcomes,
Selected Provinces/Territories, 2007–2008 to 2010–2011
SMM
Unplanned Readmission
Adjusted
Odds Ratio
95% CI
Adjusted
Odds Ratio
95% CI
Rural (vs. Urban)
1.4
1.3–1.4
1.2
1.1–1.2
Age <20 (vs. 20–34)
1.5
1.4–1.5
1.4
1.4–1.5
Age 35–39 (vs. 20–34)
1.1
1.1–1.2
1.0
1.0–1.0
Age 40+ (vs. 20–34)
1.4
1.3–1.4
1.1
1.0–1.2
MDI Quintile 2 (vs. 1)
0.9
0.9–1.0
1.0
0.9–1.0
MDI Quintile 3 (vs. 1)
0.9
0.9–1.0
1.0
0.9–1.0
MDI Quintile 4 (vs. 1)
1.0
0.9–1.0
1.0
0.9–1.1
MDI Quintile 5 (vs. 1)
1.1
1.1–1.2
1.2
1.1–1.2
Diabetes and Hypertension (vs. No Condition)
1.9
1.8–2.1
2.5
2.2–2.7
Pre-Existing Diabetes (vs. No Condition)
1.2
1.0–1.4
1.9
1.6–2.2
Gestational Diabetes (vs. No Condition)
0.9
0.9–1.0
1.1
1.0–1.2
Pre-Existing Hypertension (vs. No Condition)
2.1
1.9–2.4
2.3
2.0–2.7
Gestational Hypertension (vs. No Condition)
1.8
1.8–1.9
1.9
1.8–2.0
Multiple (vs. Singleton)
2.1
2.0–2.2
1.7
1.6–1.9
Induction
1.2
1.1–1.2
1.3
1.2–1.3
Assisted Vaginal (vs. Spontaneous Vaginal)
1.8
1.7–1.9
1.5
1.4–1.6
C-Section (vs. Spontaneous Vaginal)
3.1
3.0–3.2
2.0
2.0–2.1
Notes
SMM: severe maternal morbidity.
MDI: material deprivation index.
Source
Discharge Abstract Database, 2007–2008 to 2010–2011, Canadian Institute for Health Information.
49
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
Table A.2: Odds Ratios and Associated Confidence Intervals for Newborn Outcomes, Selected
Provinces/Territories, 2007–2008 to 2010–2011
SGA
Adjusted
Odds
Ratio
Rural (vs. Urban)
LGA
95% CI
Adjusted
Odds
Ratio
0.7
0.7–0.7
Age <20 (vs. 20–34)
1.1
Age 35–39 (vs. 20–34)
Age 40+ (vs. 20–34)
95% CI
Adjusted
Odds
Ratio
95% CI
1.4
1.4–1.4
0.9
0.9–1.0
1.1–1.2
0.9
0.9–0.9
1.2
1.2–1.3
0.9
0.9–1.0
1.1
1.1–1.1
1.0
1.0–1.0
1.1
1.0–1.1
1.0
1.0–1.0
1.1
1.1–1.2
MDI Quintile 2 (vs. 1)
1.0
1.0–1.0
1.1
1.0–1.1
1.0
1.0–1.0
MDI Quintile 3 (vs. 1)
1.1
1.1–1.1
1.0
1.0–1.0
1.0
1.0–1.0
MDI Quintile 4 (vs. 1)
1.2
1.2–1.3
1.0
1.0–1.0
1.0
1.0–1.1
MDI Quintile 5 (vs. 1)
1.3
1.3–1.3
1.0
1.0–1.0
1.1
1.1–1.2
Diabetes and Hypertension (vs. No Condition)
1.2
1.1–1.2
2.6
2.4–2.7
5.5
5.3–5.8
Pre-Existing Diabetes (vs. No Condition)
0.5
0.4–0.5
5.1
4.9–5.4
4.8
4.5–5.1
Gestational Diabetes (vs. No Condition)
0.9
0.8–0.9
1.7
1.7–1.7
1.5
1.5–1.6
Pre-Existing Hypertension (vs. No Condition)
1.8
1.7–1.9
0.9
0.8–1.0
4.6
4.3–4.9
Gestational Hypertension (vs. No Condition)
1.6
1.6–1.7
1.0
1.0–1.0
3.2
3.1–3.3
Multiple (vs. Singleton)
NA
NA
NA
NA
16.7
16.4–17.1
Induction
1.2
1.2–1.2
1.1
1.1–1.1
0.6
0.6–0.7
Assisted Vaginal (vs. Spontaneous Vaginal)
1.2
1.2–1.2
0.9
0.8–0.9
0.7
0.6–0.7
C-Section (vs. Spontaneous Vaginal)
1.0
1.0–1.0
1.6
1.5–1.6
1.2
1.2–1.3
Notes
SGA: small for gestational age.
LGA: large for gestational age.
MDI: material deprivation index.
NA: not applicable.
Source
Discharge Abstract Database, 2007–2008 to 2010–2011, Canadian Institute for Health Information.
50
Preterm
Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas
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55
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