APHEO - 10 Reproductive Health Core Indicators Documentation Report

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10 Reproductive Health Core Indicators Documentation Report

Introduction

This report documents key information used by the Reproductive Health Sub-Group (RHSG) in their revision of the reproductive health core indicators and accompanying resources.

Contents

Three data sources
Recommendations for excluding birth weights less than 500g
Home births

Section 1: Three data sources, describes why three data sources are listed for birth data in many of the reproductive health core indicators rather than a recommendation for a single source. A discussion of the strengths and limitations of the Vital Statistics birth data, hospitalization birth data, and the Better Outcomes Registry & Network (BORN) Ontario Information System (formerly the Niday Perinatal Database) is provided to help health units decide which source will work best for them.

Section 2: Recommendations for excluding birth weights less than 500g, describes the rationale for whether or not to exclude births less than 500g.

Section 3: Home births, provides information about home births under midwifery care in Ontario since home births are not included in hospitalization data.

Section 1. Three Data Sources: Why are three data sources listed for birth data rather than a recommendation for a single source?

Vital Statistics, obtained from the Office of the Registrar General through ServiceOntario, have historically provided the "official" number of live births and stillbirths; however, these data are often incomplete and out of date. The inaccuracy in the data has been documented numerous times and has led to the exclusion of Ontario data from vital statistics-based perinatal indicators in national perinatal reports produced by the Canadian Perinatal Surveillance System.¹

The RHSG originally intended to recommend that public health units use hospitalization data as the primary source for birth data. However, analysis has shown inconsistencies between hospitalization and Vital Statistics birth data that vary by health unit. In some cases, vital statistics numbers appear to be more complete. For other health units, data from the BORN Information System (historically through the Niday Perinatal Database) are the most complete source of perinatal data. Again, completeness and data quality, as well as the length of time the data have been available, vary by health unit.

As a result, the RHSG has documented the requirements for calculating indicators using all three data sources: Vital Statistics, hospitalization data, and the BORN Information System. Health units will need to decide what source to use depending upon their requirements and the data issues in their health unit area. Table 1.1 summarizes the strengths and limitations of the three sources.² For more information about these three sources, refer to the data source resources: Vital Statistics Live Birth Data, Hospitalization Data, and the BORN Information System. Table 1.2 presents the number of live births in Ontario by data source.

Table 1.1: Summary of the three sources of reproductive health data

	Vital Statistics Birth Data
General Description	Information on live births and stillbirths is collected by ServiceOntario using the birth registration form completed by parents and the Notice of Live Birth or Stillbirth form completed by the health care provider who attended the birth.* Live birth and stillbirth registration is required by law. Data access is through intelliHEALTH ONTARIO, Ministry of Health and Long-Term Care.
Years Available	1986+ (Data back to 1981 available from HELPS - see HELPS Data Source)
Strengths	Data available from 1986 onwards, providing the earliest reproductive health data of the three sources. Postal code is available for nearly all birth records. Very few birth records with missing birth weight or gestational age. Data cleaning at provincial level ensures standardized quality across Ontario. Provincial comparisons available.
Limitations	Not all births are registered and under-registration varies by geography and other characteristics. Under-registration appears more pronounced for births to teen mothers and for infants that die soon after birth.¹ Using Vital Statistics data for calculation of birth weight or gestational age-specific infant mortality or perinatal mortality rates requires an analysis file whereby the live birth registrations and the infant death registrations are linked, since birth weight information is not available on the death registration. Currently no linked file is available at the provincial level. Data generally 3-4 years out of date. Does not collect information about maternal health behaviors or breastfeeding practices. For more information about data quality, see Timeline of changes in birth registration in Ontario.

* Note that since 2010, both components of birth registration are predominantly completed online.

	Hospitalization Data
General Description	Hospitalization data include in-patient discharges resulting from a hospital admission for delivery of a live birth or stillbirth. Each delivery admission generates a maternal record (for delivery of a live birth or stillbirth) and a newborn record (for live births and stillbirths). Day procedures and emergency department visits are available through the National Ambulatory Care Reporting System (NACRS); however, births not admitted overnight are still captured in the in-patient database. Data access is through intelliHEALTH ONTARIO, Ministry of Health and Long-Term Care.
Years Available	1997+ (FY 1996/97+)
Strengths	Data are available from calendar year 1997 onwards, allowing for examination of trends over time. Data are more current compared to vital statistics. Postal code is available for nearly all birth records. Very few newborn records are missing birth weight or gestational age. Effectively captures teenage, low birth weight, preterm, and multiple births. Captures deliveries as well as births. Deliveries more accurately count pregnancies because they include stillbirths and count multiple births as one delivery/ pregnancy. Data cleaning at provincial and national level ensures standardized quality across Canada. Provincial comparisons are available.
Limitations	Excludes home births - approximately 1.7% of annual births to Ontario residents (see information in section 3 of this document). Newborn and maternal record records are separate - not all variables are available on both. Linking of maternal and newborn discharge records can be done but the linking variable is incomplete, particularly for earlier years. On the maternal record, gestational age at BIRTH is not available prior to 2007 calendar year (FY 2006/07); however, gestational age at ADMISSION for birth is available from 2003 calendar year (FY 2002/03). On the newborn record, gestational age at birth is available from 2003 calendar year (FY 2002/03). Multiple births are not available prior to 2003 calendar year. From 2003 forward (FY 2002/03), multiple births can be identified using the " Z37" code on the maternal record. Does not collect information about maternal health behaviors. Minimum one-year delay in release of data to public health.

	BORN Information System
General Description	The BORN Information System is an internet-based database that provides access to population-based perinatal data. In 2012, data from the Niday Perinatal & NICU/SCN Database, Fetal Alert Network (fetal and congenital anomalies), Prenatal Screening Ontario, Ontario Midwifery Program, and Newborn Screening Ontario were combined, along with new data in an encounter-based system, to form the BORN Information System. Prior to 2012, health units used the Niday Perinatal Database. Access to the BORN Information System is through BORN Ontario via Public Health Reports or the Public Health Data Cube. Updates and information about the BORN Information System can be found on the BORN Ontario website: http://www.bornontario.ca/.
Years Available	Historical data from Niday varies by area: 1997+ (Eastern Ontario), April 2003+ (Greater Toronto Area), 2009+ (All Ontario). The Niday online system was pilot tested in 2000, and implemented in Eastern Ontario from 2001. In 2003, Greater Toronto Area hospitals began submitting birth information. Expansion of data collection activities continued through the next five years and as of November 2009, all hospitals in Ontario with maternal-newborn services were contributing data to the Niday Perinatal Database.
Strengths	Will includes home births as of FY2012. Very few birth records are missing birth weight or gestational age. Provides extensive information about maternal and newborn characteristics. Collects information on maternal health history and behaviors, infant feeding, and maternal-newborn outcomes and health service utilization.
Limitations	All Ontario hospitals with maternal-newborn services contribute data to the BORN Information System. However, the small numbers of births that take place each year in hospitals with no obstetrical services are not captured by the database. Data capture was complete in most regions from 2005 onwards, and capture of all Ontario births was attained in Nov 2009; therefore examination of long-term trends is not possible at a provincial level or for all health unit areas. New variables added to the BORN Information System will be available as of April 2012 with no historic data. Some variables that were in the Niday Perinatal Database changed with the new system and will not be comparable with historic data.

Table 1.2: Number of live births to Ontario mothers, by data source and calendar year

Year	Vital Statistics Birth Data	Hospitalization Data	BORN Ontario*
1986	133,558
1987	134,266
1988	137,754
1989	145,021
1990	150,555
1991	151,159
1992	150,317
1993	147,544
1994	146,839
1995	146,036
1996	139,781
1997	132,799	135,931
1998	132,305	134,449
1999	130,734	132,526
2000	126,985	129,399
2001	131,360	134,136
2002	128,202	131,278
2003	130,603	134,081
2004	132,221	136,053	110,219
2005	133,485	136,845	116,089
2006	135,291	138,317	122,488
2007	138,118	140,744	132,139
2008	140,501	141,008	137,782
2009	140,074	140,609	137,954
2010	139,177	138,616	137,178
2011		138,329	137,533

* Hospital live births

References

Joseph KS. Overview. In: Canadian Perinatal Health Report, 2008 Edition. Public Health Agency of Canada. Ottawa, 2008.
Durham Region Health Department. A Comparison of Reproductive Health Data Sources Available for Durham Region. July 2009. URL: http://www.durham.ca/departments/health/health_statistics/specialReports/dataSourceCompJuly09.pdf.

Section 2. Recommendations for excluding birth weights less than 500g: What is the rationale for why some indicators should exclude births less than 500g?

Background

The rates of live births and stillbirths at the borderline of viability have been increasing in Canada. The rate of live births <500 grams (g) increased in Canada (excluding Ontario and Newfoundland and Labrador) from 4.1 per 10,000 live births in 1985 to 12.3 per 10,000 live births in 2003.¹ This rising rate has an important impact on infant mortality rates, since live births <500 g have an extremely high probability of death.² Similarly, the rate of stillbirths <500 g increased from 12.8 per 100 stillbirths in 1985 to 29.2 per 100 in 2003.¹ Over the time period of these observed increases, there have not been significant changes to the registration requirements for live births or stillbirths in Canada which would explain these trends.

A number of potential reasons behind the increases in registration of live births and stillbirths at birth weights less than 500g have been suggested, including:

Increased recognition of the registration requirements for live births and stillbirths at this birth weight
Improvements in the survival of extremely preterm and low birth weight infants
Changes in the level of recognition of these births within society
Increased frequency of live births or stillbirths <500 g due to the increasing uptake of prenatal diagnosis and pregnancy termination for serious congenital anomalies.^1,3Pregnancy terminations at 20+ weeks gestation are counted as births.

Impact of live births and stillbirths on rates of reproductive indicators

Interpretation and comparison of rates of certain reproductive health indicators can be complicated if live births and stillbirths <500 g are included in the calculations. This is particularly true for reproductive indicators that are rare - such as fetal and infant mortality rates. For example, an examination by the Canadian Perinatal Surveillance System into an apparent increase in Canadian infant mortality rates in 1993 was found to be the result of an increase in registration of live births <500 g and did not reflect increased mortality among live births ≥500 g.⁴

Table 2.1 demonstrates the effect of excluding live births and stillbirths from two indicators reported by the Canadian Perinatal Surveillance System in their 2008 report.⁵ In 2003, the crude infant mortality rate for Canada (excluding Ontario) was 5.3 per 1,000 live births. The rate decreased by 27% to 3.7 per 1,000 following the exclusion of live births <500 g from the calculation. A similar decrease can be observed for rates of fetal mortality (stillbirth).

Table 2.1: Crude and birth weight-specific rates of infant and fetal mortality, Canada,* 2003 and 2004

Indicator	Year	Numerator Size	Rate	Comments
Infant mortality - crude	2003	1,073	5.3 per 1,000 live births	There is a difference in the numerator of 315 babies between the crude and birthweight-specific rate. The infant mortality rate goes down by about 27%.
Infant mortality - ≥500 g	2003	758	3.7 per 1,000 live births
Fetal mortality - crude	2004	1,231	6.0 per 1,000 total births	There is a difference in the numerator of 359 babies between the crude and birth weight-specific rate. The rate of fetal mortality (stillbirth) goes down by about 28%.

Source: Based on data from Canadian Perinatal Health Report, 2008 Edition.⁵* Excluding the province of Ontario.

Conversely, rates for other perinatal indicators such as low birth weight or preterm birth are not strongly impacted by excluding live births <500 g given the very low frequency of <500 g / <22 week live births and the relatively high frequency of low birth weight and preterm birth rates. Table 2.2 demonstrates the effect of excluding births <500 g from three reproductive health indicators.

Excluding live births and stillbirths <500 g from the numerator and denominator in calculations of selected reproductive outcomes will help to mitigate the effect of any temporal changes in registration practices on rates. It also improves the validity of comparisons across different geographic areas, since registration practices related to births <500 g differ across jurisdictions within Canada. This is likely due to differing interpretation of the requirements for vital registration, especially with regard to pregnancy termination following diagnosis of congenital anomalies.¹

Table 2.2: Crude and birth weight-specific rates of low birth weight, preterm birth and multiple birth, Ontario, 2009

Indicator	Numerator	Denominator	Rate	Comments
Low birth weight rate (LBW) (<2,500 g) - crude	9,030	137,862	6.6 per 100 live births	There is a difference of 107 babies between the crude and birth weight-specific rate. The low birth weight rate goes down by about 1.5% after excluding live births <500 g.
Low birth weight rate (LBW) (<2,500 g) - ≥500 g	8,923	137,755	6.5 per 100 live births
Very low birth weight rate (VLBW) (<1,500 g) - crude	1,487	137,862	1.1 per 100 live births	There is a difference of 107 babies between the crude and birth weight-specific rate. The very low birth weight rate goes down by about 9.1% after excluding live births <500 g.
Very low birth weight rate (VLBW) (<1,500 g) - ≥500 g	1,380	137,755	1.0 per 100 live births
Extremely low birth weight rate (ELBW) (<1,000 g) - crude	666	137,862	0.5 per 100 live births	There is a difference of 107 babies between the crude and birth weight-specific rate. The extremely low birth weight rate goes down by about 20% after excluding live births <500 g.
Extremely low birth weight rate (ELBW) (<1,000 g) - ≥500 g	559	137,755	0.4 per 100 live births
Preterm birth (<37 weeks gestation) - crude	11,238	137,832	8.2 per 100 live births	There is a difference in the numerator of 128 babies between the crude and birth weight-specific rate. The preterm birth rate goes down by about 1.2% after excluding live births <500 g.
Preterm birth (<37 weeks gestation) - ≥500 g	11,110	137,635	8.1 per 100 live births
Multiple birth - crude	5,031	138,723	3.6 per 100 total births	There is a difference in the numerator of 48 babies between the crude and birth weight-specific rate. The multiple birth rate is unchanged after excluding live births <500 g.
Multiple birth - ≥500 g	4,983	138,268	3.6 per 100 total births

Source: BORN Ontario Database, 2009. Unpublished data for Ontario. March 2011.

Comparable Recommendations

The current practice of the Canadian Perinatal Surveillance System (CPSS) is to exclude live births and stillbirths <500 g on an ad hoc basis, depending on the purpose of the calculation. For population health surveillance reporting, this restriction is currently applied only to the calculation of infant and fetal mortality rates, and not to other indicators on which it would be expected to have minimal impact on the rates (e.g., multiple birth, preterm birth).

In the case of both the infant mortality rate and the fetal mortality rate, CPSS reports crude rates and rates ≥500 g. The basis for the latter (i.e., excluding births <500 g) is to make temporal and regional comparisons more meaningful and valid. However, the justification for also continuing to report the crude rates is that live born infants <500g represent a subgroup of babies to which tremendous medical effort and resources are often directed, which is important from a health resource perspective. Furthermore, trends in the number of live births in this birth weight category provide valuable information on local birth registration practices.⁶ For instance, jurisdictions that have few such babies (i.e., the crude infant mortality rate is approximately the same as the infant mortality rate ≥500 g) may also be under-registering live births that are near but above 500 g (e.g., 500-749 g), since routine registration of infants <500 g would tend to improve the complete registration of those just above this threshold (KS Joseph, personal written communication, 29 Jun 2010).

APHEO Guidelines

Table 2.3 presents the specific recommendations for each of the reproductive health core indicators. Note that a filter is available in IntelliHEALTH to permit exclusion of live births and stillbirths <500 g, which can be applied as per the recommendations in Table 2.3, or on an ad hoc basis, depending on the purpose of the report.
Because stillbirths <500 g may have a large effect on the stillbirth rate, it is suggested that both the crude stillbirth rate (includes all stillbirths) and the stillbirth rate ≥ 500 g be calculated. The decision of whether to present one or both will depend upon the effect and the purpose of the report.
Births <500 g should be excluded from the calculation of perinatal mortality rate. However, at present, stillbirths <500 g can be excluded, but infant deaths <500 g cannot (see Limitations for explanation). Therefore, include stillbirths <500g when calculating perinatal mortality rate until such time as infant deaths <500 g can also be excluded. Once infant deaths <500 g can also be excluded, it may be informative to compare crude perinatal mortality rate to perinatal mortality rate ≥500g.
Live births <500 g should be excluded from the calculation of neonatal and infant mortality rates; however, this requires an analysis file whereby the live birth registrations and the infant death registrations are linked, and no such file is currently available at the provincial level (see Limitations for explanation).
All statistics and tables that exclude births <500 g from the calculations should contain clear documentation indicating that this exclusion is applied (see example footnote below).

Example footnote: Over time, there has been increased registration of births with birth weight less than 500 grams. To improve comparability of this indicator over time and across jurisdictions, births under 500 grams are excluded from the calculation.

Examine trends in rates of births weighing <500 g to better understand their impact on fetal and perinatal mortality.

Limitations

Notwithstanding the APHEO guidelines above, limitations in Ontario live birth Vital Statistics data preclude calculation of birth weight-specific infant mortality rates and perinatal mortality rates (whereas stillbirths <500 g can be excluded, but infant deaths <500 g cannot). These are the reproductive indicators for which it is most important to present a rate which excludes the births <500 g from the numerator and denominator; however, to do so requires an analysis file whereby the live birth registrations and the infant death registrations are linked, since birth weight information is not available on the death registration. There is currently no linked file available at the provincial level.

References

Joseph KS. Overview. In: Canadian Perinatal Health Report, 2008 Edition. Public Health Agency of Canada. Ottawa, 2008.
Public Health Agency of Canada. Appendix G Table G25.8 Birth cohort-based infant death rate, by birth weight. In: Canadian Perinatal Health Report, 2008 Edition. Public Health Agency of Canada. Ottawa, 2008.
Liu S, Joseph KS, Kramer MS, Allen AC, Sauve R, Rusen ID, Wen SW. Relationship of prenatal diagnosis and pregnancy termination to overall infant mortality in Canada. JAMA 2002;297:1561-7.
Joseph KS, Kramer MS. Recent trends in Canadian infant mortality rates: effect of changes in registration of live newborns weighing less than 500 g. CMAJ 1996 155(8):1047-52.
Public Health Agency of Canada. Canadian Perinatal Health Report, 2008 Edition. Ottawa, 2008.
Joseph KS, Kramer MS. Recent trends in infant mortality rates and proportions of low-birthweight live births in Canada. Can Med Assoc J 1997;157:535-41.

Table 2.3: Recommendations for excluding births <500g from APHEO Reproductive Health Core Indicators*

APHEO Reproductive Health Core Indicator	Specific indicators	Excluding births <500 grams?	Comments
Crude birth rate	Crude birth rate	NO	ALL births should be included in this indicator regardless of birth weight.
Fertility rate	General fertility rate	NO	ALL births should be included in these indicators regardless of birth weight.
	Adolescent fertility rate	NO
	Age-specific fertility rate	NO
Total fertility rate	Total fertility rate	NO	ALL births should be included in this indicator regardless of birth weight.
Pregnancy rate	Total pregnancy rate	NO	ALL pregnancies should be included in these indicators regardless of birth weight.
	Age-specific pregnancy rate	NO
	Teen/Adolescent pregnancy rate	NO
Preterm birth	Rate of preterm birth (<37 weeks)	NO	The convention is to include ALL live births in the calculation of this indicator regardless of birth weight. Table 2.2 demonstrates that the impact of excluding live births <500 g for this indicator would be minimal. If undertaking a more in-depth investigation of preterm birth, it may be useful to conduct analyses by gestational age categories or birth weight categories.
	Rate of very preterm birth (<32 weeks)	NO	See above.
	Rate of moderate/late preterm birth (32 - 36 weeks)	NO	See above.
	Age-specific rate of preterm birth	NO	See above.
	Rate of post-term birth (42+ weeks)	NO	ALL live births should be included in this indicator regardless of birth weight.
Multiple birth	Rate of multiple births	NO	The convention is to include ALL births in the calculation of this indicator regardless of birth weight. Table 2.2 demonstrates that the impact of excluding births <500 g for this indicator would be minimal. If undertaking a more in-depth investigation of multiple birth, it may be useful to conduct analyses by gestational age categories or birth weight categories.
Multiple birth	Rate of multiple live births	NO	See above. Note that this specific indicator is among live births only, whereas the above include all births (i.e., live births and stillbirths).
Birth weight	Low birth weight rate (LBW) (<2,500 g)	NO	The convention is to include ALL live births in the calculation of this indicator regardless of birth weight. Table 2.2 demonstrates that the impact of excluding live births <500 g for this indicator would be minimal.
	Very low birth weight rate (VLBW) (<1,500 g)	NO
	Extremely low birth weight rate (ELBW) (<1,000 g)	NO
	Small for gestational age (proportion of singleton live births with weights below the 10th percentile of birth weights for their gestational age)	NO	ALL live births in the calculation of this indicator regardless of birth weight.
	Large for gestational age (proportion of singleton live births with weights above the 90th percentile of birth weights for their gestational age)	NO	ALL live births in the calculation of this indicator regardless of birth weight.
Congenital anomalies	Rate of congenital anomalies (CA)	NO	ALL births should be included in these indicators regardless of birth weight. A high proportion of stillbirths <500 g (40.4% in 2003) and neonatal deaths <500 g (19.7% in 2003) have congenital anomalies.† If births <500 g are excluded from the calculation, the prevalence of these congenital anomalies will be underestimated.
	Rate of neural tube defects (NTD)	NO
	Rate of Down syndrome (DS)	NO
	Rate of congenital heart defects (CHD)	NO
	Rate of orofacial clefts (OC)	NO
	Rate of musculoskeletal anomalies (MSK)	NO
Congenital infections	Incidence of reportable congenital infections (total) in live born infants	NO	ALL births should be included in these indicators regardless of birth weight. (Note also that birth weight information is not captured by iPHIS data source)
Congenital infections	Incidence of specified congenital infections in live born infants	NO
Perinatal mortality and stillbirth	Perinatal mortality rate	Ideally YES	Live births and stillbirths <500 g should be excluded from the calculation of this indicator. However, this is currently not feasible.
	Crude stillbirth rate	NO	All stillbirths (i.e. fetal deaths occurring at ≥20 weeks gestation) should be included in this indicator.
	Stillbirth rate ≥ 500 g	YES	Stillbirths <500 g should be excluded from the calculation of this indicator.
Neonatal and infant mortality	Neonatal mortality rate (0 - 27 days)	Ideally YES	Live births <500 g should be excluded from the calculation of this indicator. However, this is currently not feasible.
	Post-neonatal mortality rate (28 - 364 days)	Ideally YES	See above
	Infant mortality rate (0 - 364 days)	Ideally YES	See above
Age of parent at infant's birth	Average age of mother	NO	ALL pregnancies should be included in these indicators regardless of birth weight.
	Average age of mother at birth of first infant	NO
	Average age of father	NO
	Median age of mother	NO
	Median age of mother at birth of first infant	NO
	Median age of father	NO
	Proportion of births by age of mother	NO
	Proportion of births of first infant by age of mother	NO
	Proportion of births by age of father	NO
Folic acid supplementation	Proportion of women taking folic acid supplementation prior to pregnancy	NO	ALL pregnancies should be included in this indicator regardless of birth weight.
Folic acid supplementation	Proportion of women taking folic acid supplementation prior to and during pregnancy	NO
Smoking during pregnancy	Proportion of pregnant women who smoked tobacco during pregnancy	NO	ALL pregnancies should be included in these indicators regardless of birth weight.

*See APHEO website for further information on specific indicators: http://www.apheo.ca/index.php?pid=55#6-12
†Joseph KS. Overview. In: Canadian Perinatal Health Report, 2008 Edition. Public Health Agency of Canada. Ottawa, 2008.

Section 3: Home Births

Each year in Ontario, a small number of women choose to give birth at home under the care of a registered midwife. The Ontario Midwifery Program Maternal-Newborn Health Reporting System, administered by the Ontario Ministry of Health and Long-Term Care, records information about provision of midwifery services for the purposes of reimbursement.

Table 3.1 shows the number of midwifery-attended home births to residents of each public health unit area for two calendar years. In 2008, there was a total 2,368 midwifery home births in Ontario and a total of 138,567 hospital births (live births and stillbirths) to Ontario residents recorded in the BORN Information System. Thus, the percentage of home births in Ontario in 2008 was 1.7%.

Table 3.1: Number of women in midwifery care who gave birth at home, by public health unit, Ontario, 2008

Public health region of residence	Public health unit of residence	2008
South West	Chatham-Kent Public Health Services	8
	Elgin-St. Thomas Public Health	29
	Grey Bruce Health Unit	44
	Huron County Health Unit	26
	County of Lambton Community Health Services Dept	10
	Middlesex-London Health Unit	65
	Oxford County - Public Health & Emergency Services	26
	Perth District Health Unit	54
	Windsor-Essex County Health Unit	37
Central West	Brant County Health Unit	45
	City of Hamilton Public Health Services	111
	Haldimand-Norfolk Health Unit	35
	Halton Region Health Department	92
	Niagara Region Public Health Department	108
	Region of Waterloo, Public Health	186
	Wellington-Dufferin-Guelph Public Health	110
Toronto	Toronto Public Health	532
Central East	Durham Region Health Department	97
	Haliburton, Kawartha, Pine Ridge District Health Unit	24
	Peel Public Health	56
	Peterborough County-City Health Unit	41
	Simcoe Muskoka District Health Unit	75
	York Region Public Health Services	74
Eastern	Ottawa Public Health	191
	Eastern Ontario Health Unit	23
	Hastings & Prince Edward Counties Health Unit	29
	Kingston, Frontenac, Lennox & Addington Public Health	59
	Leeds, Grenville and Lanark District Health Unit	30
	Renfrew County & District Health Unit	19
North East	Algoma Public Health	12
	North Bay Parry Sound District Health Unit	15
	Porcupine Health Unit	<5
	Sudbury & District Health Unit	60
	Timiskaming Health Unit	<5
North West	Northwestern Health Unit	<5
North West	Thunder Bay District Health Unit	34
ONTARIO*		2,368

Source: Ontario Midwifery Program Maternal-Newborn Health Reporting System (Ontario Ministry of Health and Long-Term Care), 2008 and 2009
* The Ontario total includes 11 records for women with a midwifery-attended home birth that either could not be allocated to a public health unit or could not be reported for an individual public health unit due to a cell count <5.

Date of Last Revision: October 23, 2012

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