Maternal deaths by suicide and drug overdose in two Canadian provinces; retrospective review.

OBJECTIVE: To identify and review factors associated with maternal deaths by suicide and drug overdose in the Canadian Coroner and Medical Examiners Database (CCMED), from 2017-2019. METHODS: We identified potential maternal deaths in Ontario and British Columbia by searching the CCMED narratives of deaths to females 10 to 60 years old for pregnancy-related terms. Identified narratives were then qualitatively reviewed in quadruplicate to determine if they were maternal deaths by suicide or drug overdose, and to extract information on maternal characteristics, the manner of death, and factors associated with each death. RESULTS: Of the 90 deaths identified in this study, 15 (16.7%) were due to suicide and 20 (22.2%) were due to a drug overdose. These deaths occurred to women of varying ages and across the pregnancy-postpartum period. Among the suicides, 10 were by hanging, and among the overdose-related deaths, 15 had fentanyl detected. Notably, 13 (37.1%) of the 35 deaths to suicide or drug overdose occurred beyond 42 days after pregnancy, 19 (54.3%) followed a miscarriage or induced abortion, and in 23 (65.7%) there was an established history of mental health illness. Substance use disorders were documented in 4 of the 15 suicides (26.7%), and 18 of the 20 overdose-related deaths (90.0%). CONCLUSION: Suicide and drug overdose may contribute more to maternal deaths in Canada than previously realized. Programs are needed to identify women at risk of these outcomes, and to intervene during pregnancy and beyond the conventional postpartum period.

Diabetes mellitus in pregnancy across Canada.

BACKGROUND: Contemporary estimates of diabetes mellitus (DM) rates in pregnancy are lacking in Canada. Accordingly, this study examined trends in the rates of type 1 (T1DM), type 2 (T2DM) and gestational (GDM) DM in Canada over a 15-year period, and selected adverse pregnancy outcomes. METHODS: This study used repeated cross-sectional data from the Canadian Institute of Health Information (CIHI) hospitalization discharge abstract database (DAD). Maternal delivery records were linked to their respective birth records from 2006 to 2019. The prevalence of T1DM, T2DM and GDM were calculated, including relative changes over time, assessed by a Cochrane-Armitage test. Also assessed were differences between provinces and territories in the prevalence of DM. RESULTS: Over the 15-year study period, comprising 4,320,778 hospital deliveries in Canada, there was a statistically significant increase in the prevalence of GDM and T1DM and T2DM. Compared to pregnancies without DM, all pregnancies with any form of DM had higher rates of hypertension and Caesarian delivery, and also adverse infant outcomes, including major congenital anomalies, preterm birth and large-for-gestational age birthweight. CONCLUSION: Among 4.3 million pregnancies in Canada, there has been a rise in the prevalence of DM. T2DM and GDM are expected to increase further as more overweight women conceive in Canada.

Rates of and factors associated with exclusive and any breastfeeding at six months in Canada: an analysis of population-based cross-sectional data.

BACKGROUND: Breastfeeding has many health, economic and environmental benefits for both the infant and pregnant individual. Due to these benefits, the World Health Organization and Health Canada recommend exclusive breastfeeding for the first six months of life. The purpose of this study is to examine the prevalence of exclusive and any breastfeeding in Canada for at least six months, and factors associated with breastfeeding cessation prior to six months. METHODS: We performed a secondary analysis of breastfeeding-related questions asked on the cross-sectional 2017-2018 Canadian Community Health Survey. Our sample comprised 5,392 females aged 15-55 who had given birth in the five years preceding the survey. Descriptive statistics were carried out to assess the proportion of females exclusively breastfeeding and doing any breastfeeding for at least six months by demographic and behavioural factors. We also assessed, by baby's age, trends in the introduction of solids and liquids, breastfeeding cessation and the reasons females stopped breastfeeding. Multivariate log binominal regression was used to examine the association between breastfeeding at six months and selected maternal characteristics hypothesized a priori to be associated with breastfeeding behaviour. RESULTS: Overall, for at least six months, 35.6% (95% confidence interval (CI): 33.3%-37.8%) of females breastfed exclusively and 62.2% (95% CI: 60.0%-64.4%) did any breastfeeding. The largest decline in exclusive breastfeeding occurred in the first month. Factors most strongly associated with breastfeeding for at least six months were having a bachelor's or higher degree, having a normal body mass index, being married and daily co-sleeping. Insufficient milk supply was given as the most common reason for breastfeeding cessation irrespective of when females stopped breastfeeding. CONCLUSION: Six-month exclusive breastfeeding rates in Canada remain below targets set by the World Health Assembly. Continued efforts, including investment in monitoring of breastfeeding rates, are needed to promote and support exclusive breastfeeding, especially among females vulnerable to early cessation.

Feasibility of establishing a Canadian Obstetric Survey System (CanOSS) for severe maternal morbidity: a study protocol.

INTRODUCTION: Severe maternal morbidity (SMM)-an unexpected pregnancy-associated maternal outcome resulting in severe illness, prolonged hospitalisation or long-term disability-is recognised by many, as the preferred indicator of the quality of maternity care, especially in high-income countries. Obtaining comprehensive details on events and circumstances leading to SMM, obtained through maternity units, could complement data from large epidemiological studies and enable targeted interventions to improve maternal health. The aim of this study is to assess the feasibility of gathering such data from maternity units across Canadian provinces and territories, with the goal of establishing a national obstetric survey system for SMM in Canada. METHODS AND ANALYSIS: We propose a sequential explanatory mixed-methods study. We will first distribute a cross-sectional survey to leads of all maternity units across Canada to gather information on (1) Whether the unit has a system for reviewing SMM and the nature and format of this system, (2) Willingness to share anonymised data on SMM by direct entry using a web-based platform and (3) Respondents' perception on the definition and leading causes of SMM at a local level. This will be followed by semistructured interviews with respondent groups defined a priori, to identify barriers and facilitators for data sharing. We will perform an integrated analysis to determine feasibility outcomes, a narrative description of barriers and facilitators for data-sharing and resource implications for data acquisition on an annual basis, and variations in top-5 causes of SMM. ETHICS AND DISSEMINATION: The study has been approved by the Mount Sinai and Hamilton Integrated Research Ethics Boards. The study findings will be presented at annual scientific meetings of the Society of Obstetricians and Gynaecologists of Canada, North American Society of Obstetric Medicine, and International Network of Obstetric Survey Systems and published in an open-access peer-reviewed Obstetrics and Gynaecology or General Internal Medicine journal.

Pregnancy Outcomes During the COVID-19 Pandemic in Canada, March to August 2020.

OBJECTIVE: Several studies have documented changes in the rates preterm birth and stillbirth during the COVID-19 pandemic. We carried out a study to examine obstetric intervention, preterm birth, and stillbirth rates in Canada from March to August 2020. METHODS: The study included all singleton hospital deliveries in Canada (excluding Québec) from March to August 2020 (and March to August for the years 2015-2019) with information obtained from the Canadian Institute for Health Information. Data for Ontario were examined separately because this province had the highest rates of COVID-19 in the study population. Rates and odds ratios with 95% confidence intervals (CIs) were used to quantify pregnancy-related outcomes. RESULTS: There were 136,445 and 717,905 singleton hospital deliveries in Canada (excluding Quebéc) in from March to August 2020 and between March and August 2015-2019, respectively. Rates of obstetric intervention declined in early gestation in 2020. Odds ratios for labour induction and cesarean delivery at <32 weeks gestation for March-August 2020 versus March-August in 2015 to 2019 were 0.84 (95% CI 0.74-0.95) and 0.92 (95% CI 0.85-1.00), respectively. Preterm birth rates increased in Canada (excluding Québec) from 6.42% in March-August 2015 to 6.74% in March-August 2019 but were unchanged in March-August 2020 (6.74%). Stillbirth rates were stable between March-August 2015 and March-August 2020. However, stillbirth rates peaked in Ontario in April 2020 due to higher rates of stillbirths at 20-27 and 37-41 weeks gestation. CONCLUSION: Changes in labour induction and cesarean delivery at early gestation and other perinatal outcomes during the period of March to August 2020 highlight the need to reconsider the use and impact of obstetric services in pandemics as well as the need for timely perinatal surveillance.

Database Autopsy: An Efficient and Effective Confidential Enquiry into Maternal Deaths in Canada.

BACKGROUND: Maternal death surveillance in Canada relies on hospitalization data, which lacks information on the underlying cause of death. We developed a method for identifying underlying causes of maternal death, and quantified the frequency of maternal death by cause. METHODS: We used data from the Discharge Abstract Database for fiscal years 2013 to 2017 to identify women who died in Canadian hospitals (excluding Quebec) while pregnant or within 1 year of the end of pregnancy. A sequential narrative based on hospital admission(s) during and after pregnancy was constituted and reviewed to assign the underlying cause of death (based on the World Health Organization's framework). Maternal deaths (i.e., while pregnant or within 42 days after the end of pregnancy) and late maternal deaths (i.e., more than 42 days to a year after the end of pregnancy) were examined separately. RESULTS: We identified 85 maternal deaths. Direct obstetric causes included 8 deaths (9%) related to complications of spontaneous or induced abortion; 9 (11%), to hypertensive disorders of pregnancy; 15 (18%), to obstetric hemorrhage; 11 (13%), to pregnancy-related infection; 16 (19%), to other obstetric complications; and <5 (<6%), to complications of management. There were 21 (25%) maternal deaths with indirect obstetric causes, and <5 (<6%) with undetermined causes. Of 120 late maternal deaths, 16 (13%) had direct obstetric causes, among them, 9 deaths by suicide (56%). One hundred late maternal deaths (83%) had indirect obstetric causes; and <5 (<4%) had undetermined causes. CONCLUSIONS: The majority of maternal deaths in Canada have direct obstetric causes, whereas most late maternal deaths have indirect obstetric causes. Suicide is an important direct cause of late maternal death.

Severe maternal morbidity surveillance: Monitoring pregnant women at high risk for prolonged hospitalisation and death.

BACKGROUND: There is no international consensus on the definition and components of severe maternal morbidity (SMM). OBJECTIVES: To propose a comprehensive definition of SMM, to create an empirically justified list of SMM types and subtypes, and to use this to examine SMM in Canada. METHODS: Severe maternal morbidity was defined as a set of heterogeneous maternal conditions known to be associated with severe illness and with prolonged hospitalisation or high case fatality. Candidate SMM types/subtypes were evaluated using information on all hospital deliveries in Canada (excluding Quebec), 2006-2015. SMM rates for 2012-2016 were quantified as a composite and as SMM types/subtypes. Rate ratios and population attributable fractions (PAF) associated with overall and specific SMM types/subtypes were estimated in relation to length of hospital stay (LOS > 7 days) and case fatality. RESULTS: There were 22 799 cases of SMM subtypes (among 1 418 545 deliveries) that were associated with a prolonged LOS or high case fatality. Between 2012 and 2016, the composite SMM rate was 16.1 (95% confidence interval [CI] 15.9, 16.3) per 1000 deliveries. Severe pre-eclampsia and HELLP syndrome (514.6 per 100 000 deliveries), and severe postpartum haemorrhage (433.2 per 100 000 deliveries) were the most common SMM types, while case fatality rates among SMM subtypes were highest among women who had cardiac arrest and resuscitation (241.1 per 1000), hepatic failure (147.1 per 1000), dialysis (67.6 per 1000), and cerebrovascular accident/stroke (51.0 per 1000). The PAF for prolonged hospital stay related to SMM was 17.8% (95% CI 17.3, 18.3), while the PAF for maternal death associated with SMM was 88.0% (95% CI 74.6, 94.4). CONCLUSIONS: The proposed definition of SMM and associated list of SMM subtypes could be used for standardised SMM surveillance, with rate ratios and PAFs associated with specific SMM types/subtypes serving to inform clinical practice and public health policy.

Severe Maternal Morbidity in Canada: Temporal Trends and Regional Variations, 2003-2016.

OBJECTIVE: This study sought to quantify temporal trends and provincial and territorial variations in severe maternal morbidity (SMM) in Canada. METHODS: The study used data on all hospital deliveries in Canada (excluding Québec) from 2003 to 2016 to examine temporal trends and from 2012 to 2016 to study regional variations. SMM was identified using diagnosis and intervention codes. Contrasts among periods and regions were quantified using rate ratios (RRs) and 95% confidence intervals (CIs). Temporal changes were also assessed using chi-square tests for trend (Canadian Task Force Classification II-1). RESULTS: The study population included 3 882 790 deliveries between 2003 and 2016 and 1 418 545 deliveries between 2012 and 2016. Severe hemorrhage rates increased from 44.8 in 2003 to 62.4 per 10 000 deliveries in 2012 (P for trend <0.0001) and then declined to 41.8 per 10 000 deliveries in 2016 (P for trend <0.0001). Maternal intensive care unit admission and sepsis rates decreased between 2003 and 2016, whereas rates of stroke, severe uterine rupture, hysterectomy, obstetric embolism, shock, and assisted ventilation increased. Rates of composite SMM in 2012-2016 were higher in Newfoundland and Labrador (RR 1.15; 95% CI 1.04-1.26), Nova Scotia (RR 1.11; 95% CI 1.03-1.19), New Brunswick (RR1.22; 95% CI 1.13-1.32), Manitoba (RR 1.09; 95% CI 1.03-1.15), Saskatchewan (RR 1.15; 95% CI 1.09-1.22), the Yukon (RR 1.74; 95% CI 1.35-2.25), and Nunavut (RR 1.76; 95% CI 1.46-2.11) compared with the rest of Canada, whereas rates were lower in Alberta and British Columbia. CONCLUSION: This surveillance report helps inform clinical practice and public health policy for improving maternal health in Canada.

Interprovincial variation in pre-pregnancy body mass index and gestational weight gain and their impact on neonatal birth weight with respect to small and large for gestational age.

OBJECTIVES: To explore provincial variation in both excess and inadequate pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) and their impact on small- and large-for-gestational-age (SGA, LGA) infants. METHODS: Four provinces with a perinatal database capturing the required exposures participated: British Columbia (BC), Ontario (ON), Nova Scotia (NS), and Newfoundland and Labrador (NL). In multiple, concurrent retrospective studies, we included women ≥ 19 years, who gave birth from 22+0 to 42+6 weeks' gestation, to a live singleton from April 2013-March 2014. From adjusted odds ratios, we calculated population attributable fractions (PAF) of SGA and LGA for BMI and GWG. RESULTS: The proportion of overweight and obese women increased from western to eastern Canada. In BC, ON, NS, and NL, the proportions of women who were overweight were 21.1%, 24.0%, 23.7%, and 25.4%, while obesity proportions were 14.2%, 18.1%, 24.2%, and 29.8%, respectively. Excess GWG affected 53.9%, 49.9%, 57.6%, and 65.6% of women, respectively. Excess GWG contributed to 29.5-42.5% of LGA, compared with the PAFs for overweight (6.8-12.0%) and obesity (13.2-20.6%). Inadequate GWG's contribution to SGA (4.8-12.3%) was higher than underweight BMI's (2.9-6.2%). CONCLUSION: In this interprovincial study, high and increasing proportions of women from west to east had excess pre-pregnancy BMI, and between half to two thirds had excess GWG. The contributions of GWG outside of recommendations to SGA and LGA were greater than that of low or high BMI. GWG is a potentially modifiable determinant of SGA and LGA across Canada.

Prevalence of Severe Maternal Morbidity and Factors Associated With Maternal Mortality in Ontario, Canada.

Importance: Severe maternal morbidity is defined by potentially life-threatening conditions. The association between the number of severe maternal morbidity (SMM) indicators and maternal death is not known. Objective: To quantify the association between the number of SMM indicators and maternal mortality. Design, Setting, and Participants: This population-based cohort study used provincial databases for data on all live birth and stillbirth hospital deliveries among women in Ontario, Canada, from April 1, 2002, to February 18, 2017. Excluded from this cohort were those with invalid identification number, non-Ontario residency, maternal age younger than 10 years or older than 55 years or unknown, or gestational age fewer than 20 weeks or unknown as well as any out-of-hospital births, ectopic pregnancies, or spontaneous or induced abortions. Exposures: Number of SMM indicators identified between 20 weeks' gestation and 42 days after the index delivery. Main Outcomes and Measures: Maternal death occurring from delivery to 42 days after the index delivery. Results: Of the 1 953 943 total births among 1 211 396 women, 181 maternal deaths occurred within 42 days after birth, a rate of 9.3 per 100 000 births. Of the 181 women who died, 123 (68.0%) had at least 1 SMM indicator compared with 1.7% (33 152) of women who survived. Standardized differences suggested that women who died, compared with the women who lived, were older (mean [SD] age, 31.0 [6.2] years vs 30.1 [5.5] years; standardized difference, 0.15) and more likely to reside in a lower-income area (99 [54.7%] vs 832 231 [42.6%]; standardized difference, 0.24), be nulliparous (93 [51.4%] vs 880 386 [45.1%]; standardized difference, 0.13), and be of Afro-Caribbean origin (12 [6.6%] vs 64 948 [3.3%]; standardized difference, 0.15). The most frequent SMM indicators were intensive care unit admission (81 [44.8%]), invasive ventilation (77 [42.5%]), cardiac conditions (69 [38.1%]), complications of obstetric surgery or procedures (32 [17.7%]), and postpartum hemorrhage with blood transfusion (31 [17.1%]). The rate of maternal mortality increased exponentially with the number of SMM indicators: 0 indicators (3.0 per 100 000 births), 1 (71.7 per 100 000 births), 2 (385.9 per 100 000 births), 3 (1274.2 per 100 000 births), 4 (2236.8 per 100 000 births), 5 (4285.7 per 100 000 births), and 6 or more (9422.5 per 100 000 births). Adjusted relative risks for maternal death ranged from 20.1 (95% CI, 11.6-34.7) with 1 SMM indicator to 2192.0 (95% CI, 1287.0-3735.0) with 6 or more SMM indicators compared with 0 indicators. Conclusions and Relevance: Maternal death may be associated with the number of SMM indicators and occur in certain identifiable groups of women; targeting preventable SMM indicators or limiting their progression may reduce the number of maternal deaths.

Estimated reductions in provider-initiated preterm births and hospital length of stay under a universal acetylsalicylic acid prophylaxis strategy: a retrospective cohort study.

BACKGROUND: Hypertensive disorders, especially preeclampsia, are the leading reason for provider-initiated preterm birth. We estimated how universal acetylsalicylic acid (ASA) prophylaxis might reduce rates of provider-initiated preterm birth associated with preeclampsia and intrauterine growth restriction, which are related conditions. METHODS: We performed a cohort study of singleton hospital births in 2013 in Canada, excluding Quebec. We estimated the proportion of term births and provider-initiated preterm births affected by preeclampsia and/or intrauterine growth restriction, and the corresponding mean maternal and newborn hospital length of stay. We projected the potential number of cases reduced and corresponding hospital length of stay if ASA prophylaxis lowered cases of preeclampsia and intrauterine growth restriction by a relative risk reduction (RRR) of 10% (lowest) or 53% (highest), as suggested by randomized clinical trials. RESULTS: Of the 269 303 singleton live births and stillbirths in our cohort, 4495 (1.7%) were provider-initiated preterm births. Of the 4495, 1512 (33.6%) had a diagnosis of preeclampsia and/or intrauterine growth restriction. The mean maternal length of stay was 2.0 (95% confidence interval [CI] 2.0-2.0) days among term births unaffected by either condition and 7.3 (95% CI 6.1-8.6) days among provider-initiated preterm births with both conditions. The corresponding values for mean newborn length of stay were 1.9 (95% CI 1.8-1.9) days and 21.8 (95% CI 17.4-26.2) days. If ASA conferred a 53% RRR against preeclampsia and/or intrauterine growth restriction, 3365 maternal and 11 591 newborn days in hospital would be averted. If ASA conferred a 10% RRR, 635 maternal and 2187 newborn days in hospital would be averted. INTERPRETATION: A universal ASA prophylaxis strategy could substantially reduce the burden of long maternal and newborn hospital stays associated with provider-initiated preterm birth. However, until there is compelling evidence that administration of ASA to all, or most, pregnant women reduces the risk of preeclampsia and/or intrauterine growth restriction, clinicians should continue to follow current clinical practice guidelines.

Changes in the incidence and surgical treatment of ankyloglossia in Canada.

BACKGROUND: Recent reports show increases in rates of ankyloglossia and frenotomy in British Columbia. We carried out a study to determine temporal trends and regional variations in ankyloglossia and frenotomy in Canada. METHODS: The study included all hospital-based live births in Canada (excluding Quebec) between April 2002 and March 2015, with information obtained from the Canadian Institute for Health Information. Information on ankyloglossia and frenotomy was obtained from records of hospital admission for childbirth. Temporal trends and provincial/territorial variations were quantified using rate ratios (RR) and 95% confidence intervals (CI). RESULTS: Ankyloglossia rates increased from 6.86 in 2002 to 22.6 per 1000 live births in 2014 (P for trend < 0.001), while frenotomy rates increased from 3.76 in 2002 to 14.7 per 1000 live births in 2014 (P for trend < 0.001). Frenotomy rates among infants with ankyloglossia increased from 54.7% in 2002 to 63.9% in 2014 (RR: 1.18, 95% CI: 1.13-1.24). Compared with British Columbia, rates of ankyloglossia were over three-fold higher in Saskatchewan (RR: 3.40, 95% CI: 3.16-3.67), Alberta (RR: 3.50, 95% CI: 3.29-3.72) and the Yukon (RR: 3.62, 95% CI: 2.67-4.92), while rates of frenotomy were three- to four-fold higher in the Yukon (RR: 3.41, 95% CI: 2.28-5.10), Alberta (RR: 4.01, 95% CI: 3.71-4.33) and Saskatchewan (RR: 4.12, 95% CI: 3.76-4.52). CONCLUSION: A desire to increase rates of breast feeding initiation and absence of standardized criteria for the diagnosis of ankyloglossia have resulted in runaway rates of frenotomy for newborn infants in some parts of Canada.

Prevalence of gestational diabetes among Chinese and South Asians: A Canadian population-based analysis.

BACKGROUND: There is considerable geographic variation in gestational diabetes mellitus (GDM) rates. We used data from two Canadian provinces, British Columbia (BC) and Alberta (AB), to determine the impact of ethnicity on GDM prevalence and neonatal outcomes. RESEARCH DESIGN AND METHODS: All deliveries between 04/01/2004 and 03/31/2010 in AB (n=249,796) and BC (n=248,217) were analyzed. We calculated GDM prevalence among Chinese, South-Asian, and the general population (predominantly Caucasian) women. RESULTS: Overall GDM prevalence was 4.8% (n=12,036) in AB and 7.2% (n=17,912) in BC. In both provinces, the prevalence of GDM was significantly higher in Chinese (AB:11%; BC:13.5%) and South Asian women (AB:8.4%;BC:13.9%) compared to the general population (AB:4.2%; BC: 5.8%). Chinese women were significantly older (AB:32.7; BC:33.0years) compared to the general population (AB:29.1; BC:30.1years). The odds of GDM relative to the general-population were 2-fold higher for South Asians in both provinces and almost 3-fold higher for Chinese in BC. Among GDM cases, compared to the general population, Chinese and South Asian infants were less likely to be LGA, more likely to be SGA, and had similar neonatal mortality rates. CONCLUSIONS: Compared to the general population, GDM prevalence is higher in Chinese and South Asian Canadians. Increased maternal age is a major contributor to higher prevalence of GDM in Chinese women. GDM rates were higher in both ethnic and general population women in BC compared to AB, suggesting that in addition to differences in ethnic distribution, differences in diagnostic practices are likely contributing to observed geographic differences in GDM prevalence.

Contribution of prepregnancy body mass index and gestational weight gain to adverse neonatal outcomes: population attributable fractions for Canada.

BACKGROUND: Low or high prepregnancy body mass index (BMI) and inadequate or excess gestational weight gain (GWG) are associated with adverse neonatal outcomes. This study estimates the contribution of these risk factors to preterm births (PTBs), small-for-gestational age (SGA) and large-for-gestational age (LGA) births in Canada compared to the contribution of prenatal smoking, a recognized perinatal risk factor. METHODS: We analyzed data from the Canadian Maternity Experiences Survey. A sample of 5,930 women who had a singleton live birth in 2005-2006 was weighted to a nationally representative population of 71,200 women. From adjusted odds ratios, we calculated population attributable fractions to estimate the contribution of BMI, GWG and prenatal smoking to PTB, SGA and LGA infants overall and across four obstetric groups. RESULTS: Overall, 6% of women were underweight (<18.5 kg/m(2)) and 34.4% were overweight or obese (≥25.0 kg/m(2)). More than half (59.4%) gained above the recommended weight for their BMI, 18.6% gained less than the recommended weight and 10.4% smoked prenatally. Excess GWG contributed more to adverse outcomes than BMI, contributing to 18.2% of PTB and 15.9% of LGA. Although the distribution of BMI and GWG was similar across obstetric groups, their impact was greater among primigravid women and multigravid women without a previous PTB or pregnancy loss. The contributions of BMI and GWG to PTB and SGA exceeded that of prenatal smoking. CONCLUSIONS: Maternal weight, and GWG in particular, contributes significantly to the occurrence of adverse neonatal outcomes in Canada. Indeed, this contribution exceeds that of prenatal smoking for PTB and SGA, highlighting its public health importance.

Patterns of social inequalities across pregnancy and birth outcomes: a comparison of individual and neighborhood socioeconomic measures.

BACKGROUND: This paper identifies patterns of health inequalities (consistency and magnitude) of socioeconomic disparities for multiple maternal and child health (MCH) outcomes that represent different health care needs of mothers and infants. METHODS: Using cross-sectional national data (unweighted sample = 6,421, weighted =76,508) from the Canadian Maternity Experiences Survey linked with 2006 Canadian census data, we categorized 25 health indicators of mothers of singletons into five groups of MCH outcomes (A. maternal and infant health status indicators; B. prenatal care; C. maternal experience of labor and delivery; D. neonatal medical care; and E. postpartum infant care and maternal perceptions of health care services). We then examined the association of these health indicators with individual socioeconomic position (SEP) (education and income), neighborhood SEP and combined SEP (a four-level measure of low and high individual and neighborhood SEP), and compared the magnitude (odds ratios and 95% confidence intervals) and direction of the associations within and between MCH outcome groups. RESULTS: We observed consistent positive gradients of socioeconomic inequalities within most groups and for 23/25 MCH outcomes. However, more significant associations and stronger gradients were observed for the MCH outcomes in the maternal and infant health status group as opposed to other groups. The neonatal medical care outcomes were weakly associated with SEP. The direction of associations was negative between some SEP measures and HIV testing, timing of the first ultrasound, caesarean section, epidural for vaginal births, infant needing non-routine neonatal care after discharge and any breastfeeding at 3 or 6 months. Gradients were steep for individual SEP but moderate for neighborhood SEP. Combined SEP had no consistent gradients but the subcategory of low individual-high neighborhood SEP often showed the poorest health outcomes compared to the categories within this SEP grouping. CONCLUSION: By examining SEP gradients in multiple MCH outcomes categorized into groups of health care needs, we identified large and consistent inequalities both within and between these groups. Our results suggest differences in pathways and mechanisms contributing to SEP inequalities across groups of MCH outcomes that can be examined in future research and inform prioritization of policies for reducing these inequalities.

Contribution of prepregnancy body mass index and gestational weight gain to caesarean birth in Canada.

BACKGROUND: Overweight and obese women are known to be at increased risk of caesarean birth. This study estimates the contribution of prepregnancy body mass index (BMI) and gestational weight gain (GWG) to caesarean births in Canada. METHODS: We analyzed data from women in the Canadian Maternity Experiences Survey who had a singleton term live birth in 2005-2006. Adjusted odds ratios for caesarean birth across BMI and GWG groups were derived, separately for nulliparous women and parous women with and without a prior caesarean. Population attributable fractions of caesarean births associated with above normal BMI and excess GWG were calculated. RESULTS: The overall caesarean birth rate was 25.7%. Among nulliparous and parous women without a previous caesarean birth, rates in obese women were 45.1% and 9.7% respectively, and rates in women who gained above their recommended GWG were 33.5% and 8.0% respectively. Caesarean birth was more strongly associated with BMI than with GWG. However, due to the high prevalence of excess GWG (48.8%), the proportion of caesareans associated with above normal BMI and excess GWG was similar [10.1% (95% CI: 9.9-10.2) and 10.9% (95% CI: 10.7-11.1) respectively]. Overall, one in five (20.2%, 95% CI: 20.0-20.4) caesarean births was associated with above normal BMI or excess GWG. CONCLUSIONS: Overweight and obese BMI and above recommended GWG are significantly associated with caesarean birth in singleton term pregnancies in Canada. Strategies to reduce caesarean births must include measures to prevent overweight and obese BMI prior to conception and promote recommended weight gain throughout pregnancy.

Impact of user fees on maternal health service utilization and related health outcomes: a systematic review.

OBJECTIVE: To assess the evidence of the impact of user fees on maternal health service utilization and related health outcomes in low- and middle-income countries, as well as their impact on inequalities in these outcomes. METHODS: Studies were identified by modifying a search strategy from a related systematic review. Primary studies of any design were included if they reported the effect of fee changes on maternal health service utilization, related health outcomes and inequalities in these outcomes. For each study, data were systematically extracted and a quality assessment conducted. Due to the heterogeneity of study methods, results were examined narratively. FINDINGS: Twenty studies were included. Designs and analytic approaches comprised: two interrupted time series, eight repeated cross-sectional, nine before-and-after without comparison groups and one before-and-after in three groups. Overall, the quality of studies was poor. Few studies addressed potential sources of bias, such as secular trends over time, and even basic tests of statistical significance were often not reported. Consistency in the direction of effects provided some evidence of an increase in facility delivery in particular after fees were removed, as well as possible increases in the number of managed delivery complications. There was little evidence of the effect on health outcomes or inequality in accessing care and, where available, the direction of effect varied. CONCLUSION: Despite the global momentum to abolish user fees for maternal and child health services, robust evidence quantifying impact remains scant. Improved methods for evaluating and reporting on these interventions are recommended, including better descriptions of the interventions and context, looking at a range of outcome measures, and adopting robust analytical methods that allow for adjustment of underlying and seasonal trends, reporting immediate as well as longer-term (e.g. at 6 months and 1 year) effects and using comparison groups where possible.

Impact of free delivery care on health facility delivery and insurance coverage in Ghana's Brong Ahafo Region.

BACKGROUND: Many sub-Saharan countries, including Ghana, have introduced policies to provide free medical care to pregnant women. The impact of these policies, particularly on access to health services among the poor, has not been evaluated using rigorous methods, and so the empirical basis for defending these policies is weak. In Ghana, a recent report also cast doubt on the current mechanism of delivering free care--the National Health Insurance Scheme. Longitudinal surveillance data from two randomized controlled trials conducted in the Brong Ahafo Region provided a unique opportunity to assess the impact of Ghana's policies. METHODS: We used time-series methods to assess the impact of Ghana's 2005 policy on free delivery care and its 2008 policy on free national health insurance for pregnant women. We estimated their impacts on facility delivery and insurance coverage, and on socioeconomic differentials in these outcomes after controlling for temporal trends and seasonality. RESULTS: Facility delivery has been increasing significantly over time. The 2005 and 2008 policies were associated with significant jumps in coverage of 2.3% (p = 0.015) and 7.5% (p<0.001), respectively after the policies were introduced. Health insurance coverage also jumped significantly (17.5%, p<0.001) after the 2008 policy. The increases in facility delivery and insurance were greatest among the poorest, leading to a decline in socioeconomic inequality in both outcomes. CONCLUSION: Providing free care, particularly through free health insurance, has been effective in increasing facility delivery overall in the Brong Ahafo Region, and especially among the poor. This finding should be considered when evaluating the impact of the National Health Insurance Scheme and in supporting the continuation and expansion of free delivery care.

Factors associated with perceived stress and stressful life events in pregnant women: findings from the Canadian Maternity Experiences Survey.

Prenatal maternal stress has been linked to multiple adverse outcomes. Researchers have used a variety of methods to assess maternal stress. The purpose of this study was to explore and compare factors associated with stress in pregnancy as measured by perceived stress and stressful life events. We analyzed data from the Canadian Maternity Experiences Survey. A randomly selected sample of 8,542 women who had recently given birth was drawn from the 2006 Canadian Census. Women were eligible if they were at least 15 years of age, had delivered a live, singleton infant, and were living with their infant at the time of the interview (5-14 months postpartum). Prevalence estimates and odds ratios were calculated using sample weights of the survey and their variances were calculated using bootstrapping methods. Bivariate analyses identified statistically significant factors associated with each stress measure. Backward stepwise multivariate logistic regression models were constructed. A total of 6,421 women (78%) participated in the computer assisted telephone interview. Twelve percent of women experienced high levels of perceived stress and 17.1% reported having three or more stressful life events in the year prior to the birth of their baby. In the final model, psychosocial variables were associated with both outcomes, whereas demographic factors were associated only with life event stress. Different factors contributed to perceived stress and life event stress, suggesting that these concepts measure different aspects of stress. These findings can inform routine psychosocial risk assessment in pregnancy.