Education Outcomes of Children Born Late Preterm: A Retrospective Whole-Population Cohort Study.

BACKGROUND: Early life exposures can have an impact on a child's developmental trajectory and children born late preterm (34-36 weeks gestational age) are increasingly recognized to have health and developmental setbacks that extend into childhood. OBJECTIVES: The purpose of this study was to assess whether late preterm birth was associated with poorer developmental and educational outcomes in the early childhood period, after controlling for health and social factors. METHODS: We conducted a retrospective cohort study using administrative databases housed at the Manitoba Centre for Health Policy, including all children born late preterm (34-36 weeks gestational age (GA)) and at full-term (39-41 weeks GA) between 2000 and 2005 in urban Manitoba (N = 28,100). Logistic regression was used to examine the association between gestational age (GA) and outcomes, after adjusting for covariates. RESULTS: Adjusted analyses demonstrated that children born late preterm had a higher prevalence of attention deficit hyperactivity disorder (ADHD) (aOR = 1.25, 95% CI [1.03, 1.51]), were more likely to be vulnerable in the language and cognitive (aOR = 1.29, 95% CI [1.06, 1.57]), communication and general knowledge (aOR = 1.24, 95% CI [1.01, 1.53]), and physical health and well-being (aOR = 1.27, 95% CI [1.04, 1.53]) domains of development at kindergarten, and were more likely to repeat kindergarten or grade 1 (aOR = 1.52, 95% CI [1.03, 2.25]) compared to children born at term. They did not differ in receipt of special education funding, in social maturity or emotional development at kindergarten, and in reading and numeracy assessments in the third grade. CONCLUSIONS: Given that the late preterm population makes up 75% of the preterm population, their poorer outcomes have implications at the population level. This study underscores the importance of recognizing the developmental vulnerability of this population and adequately accounting for the social differences between children born late preterm and at term.

Does First Nations ancestry modify the association between gestational diabetes and subsequent diabetes: a historical prospective cohort study among women in Manitoba, Canada.

BACKGROUND: Over the past 30 years, the prevalence of diabetes has steadily increased among Canadians, and is particularly evident among First Nations (FN) women. The interplay between FN ancestry, gestational diabetes and the development of subsequent diabetes among mothers remains unclear. METHODS: After excluding known pre-existing diabetes, we explored whether FN ancestry may modify the association between gestational diabetes and post-partum diabetes among women in Manitoba (1981-2011) via a historical prospective cohort database study. We analysed administrative data in the Population Health Research Data Repository using Kaplan-Meier survival analysis and Cox proportional hazards regression. RESULTS: Gestational diabetes was diagnosed in 11 906 of 404 736 deliveries (2.9%), 6.7% of FN and 2.2% of non-FN pregnant women (P < 0.0001). Post-partum diabetes during ≤ 30 years follow-up was more than three times higher among FN women than among non-FN women (P < 0.0001). Diabetes developed in 76.0% of FN and 56.2% of non-FN women with gestational diabetes within the follow-up period. The hazard ratio of gestational diabetes for post-partum diabetes was 10.6 among non-FN women and 5.4 among FN women. Other factors associated with a higher risk of diabetes included lower family income among FN and non-FN women and rural/remote residences among FN women. Among non-FN women, urban residence was associated with a higher risk of diabetes. CONCLUSION: Gestational diabetes increases post-partum diabetes in FN and non-FN women. FN women had substantially more gestational diabetes or post-partum diabetes than non-FN women, partially due to socio-economic and environmental barriers. Reductions in gestational diabetes and socio-economic inequalities are required to prevent diabetes in women, particularly in FN population.

Migrant women's utilization of prenatal care: a systematic review.

Our objectives were to determine whether migrant women in Western industrialized countries have higher odds of inadequate prenatal care (PNC) compared to receiving-country women and to summarize factors that are associated with inadequate PNC among migrant women in these countries. We conducted searches of electronic databases (MEDLINE, EMBASE, and PsycINFO), reference lists, known experts, and an existing database of the Reproductive Outcomes And Migration international research collaboration for articles published between January, 1995 and April, 2010. Title and abstract review and quality appraisal were conducted independently by 2 reviewers using established criteria, with consensus achieved through discussion. In this systematic review of 29 studies, the majority of studies demonstrated that migrant women were more likely to receive inadequate PNC than receiving-country women, with most reporting moderate to large effect sizes. Rates of inadequate PNC among migrant women varied widely by country of birth. Only three studies explored predictors of inadequate PNC among migrant women. These studies found that inadequate PNC among migrant women was associated with being less than 20 years of age, multiparous, single, having poor or fair language proficiency, education less than 5 years, an unplanned pregnancy, and not having health insurance. We concluded that migrant women as a whole were more likely to have inadequate PNC and the magnitude of this risk differed by country of origin. Few studies addressed predictors of PNC utilization in migrant women and this limits our ability to provide effective PNC in this population.

Primary birthing attendants and birth outcomes in remote Inuit communities--a natural "experiment" in Nunavik, Canada.

BACKGROUND: There is a lack of data on the safety of midwife-led maternity care in remote or indigenous communities. In a de facto natural "experiment", birth outcomes were assessed by primary birthing attendant in two sets of remote Inuit communities. METHODS: A geocoding-based retrospective birth cohort study in 14 Inuit communities of Nunavik, Canada, 1989-2000: primary birth attendants were Inuit midwives in the Hudson Bay (1529 Inuit births) vs western physicians in Ungava Bay communities (1197 Inuit births). The primary outcome was perinatal death. Secondary outcomes included stillbirth, neonatal death, post-neonatal death, preterm, small-for-gestational-age and low birthweight birth. Multilevel logistic regression was used to obtain the adjusted odds ratios (aOR) controlling for maternal age, marital status, parity, education, infant sex and plurality, community size and community-level random effects. RESULTS: The aORs (95% confidence interval) for perinatal death comparing the Hudson Bay vs Ungava Bay communities were 1.29 (0.63 to 2.64) for all Inuit births and 1.13 (0.48 to 2.47) for Inuit births at > or =28 weeks of gestation. There were no statistically significant differences in the crude or adjusted risks of any of the outcomes examined. CONCLUSION: Risks of perinatal death were somewhat but not significantly higher in the Hudson Bay communities with midwife-led maternity care compared with the Ungava Bay communities with physician-led maternity care. These findings are inconclusive, although the results excluding extremely preterm births are more reassuring concerning the safety of midwife-led maternity care in remote indigenous communities.

Complicated and uncomplicated pregnancies: women's perception of risk.

OBJECTIVE: To compare the perception of risk of women with complicated and uncomplicated pregnancies and to determine the relationship between biomedical, psychosocial, and demographic risk factors and women's personal perceptions of pregnancy risk. DESIGN: A descriptive, correlational study. SETTING: Antenatal units and outpatient clinics of two tertiary care teaching hospitals in western Canada. PATIENTS/PARTICIPANTS: A convenience sample of 105 women having a complicated pregnancy requiring hospitalization for more than 48 hours and 103 women with no known complications and no hospitalization during the pregnancy. MAIN OUTCOME MEASURE: Perception of risk during pregnancy. RESULTS: Women with complicated pregnancies perceived their overall risk and risk for specific pregnancy outcomes as significantly higher than women with uncomplicated pregnancies. State anxiety and biomedical risk were positively related to perception of risk, but there was no relationship between stress, self-esteem, or social support and perception of risk. The strongest predictors of self-perception of pregnancy risk were the biomedical risk score and state anxiety. CONCLUSION: Women with complicated pregnancies perceive their risks as higher than women with uncomplicated pregnancies. Both biomedical and psychosocial factors play a role in influencing risk perception. Nursing assessment of the pregnant woman should include discussion with her of her perception of risk.

Reducing the preterm birth rate: a population health strategy.

The rate of preterm birth has been increasing in Canada and the United States. Efforts to prevent preterm birth have been largely ineffective. A population health strategy that integrates disease prevention and health promotion is needed. In this article, the five categories of health determinants proposed by the Federal, Provincial and Territorial Advisory Committee on Population Health are used as a framework to discuss risk factors and propose policies and interventions to reduce the preterm birth rate.

Conducting health research with vulnerable women: issues and strategies.

This paper has summarized a variety of methodological and ethical issues in conducting research with vulnerable women, and has also proposed strategies for dealing with these issues. Because vulnerable women are at increased risk for health problems, it is imperative that nurses and other health-care professionals make strenuous efforts to include vulnerable women in health research.

Leadership: the Winnipeg Community and Long-Term Care Authority.

The Winnipeg Community and Long Term Care Authority (WCA) was established in 1998 under the Regional Health Authorities Act of the Province of Manitoba. The WCA's role is to provide for the successful integration of Winnipeg's community-based healthcare delivery services through its three main portfolios: Community Care and Public Health, Home Care and Mental Health, and Long Term Care and Specialized Services. The WCA is dedicated to building a quality health future for Winnipeg. Various initiatives undertaken in the pursuit of quality are described.

Antepartum home care for high-risk pregnant women.

Home care for women experiencing complications of pregnancy is a rapidly growing specialty. A variety of models of antepartum home care have emerged. Provision of effective antepartum home care requires knowledge and clinical skills in perinatal and home health nursing and an understanding of the structure and function of the home health care system. Nursing care in the home encompasses case coordination, maternal and fetal assessment, maternal education regarding the woman's risk situation and self-monitoring requirements, and provision of support. Antepartum home care for conditions such as hypertension in pregnancy, preterm labor, and hyperemesis gravidarum is discussed.

Psychosocial impact of high-risk pregnancy: hospital and home care.

This article has reviewed research on the psychosocial impact of high-risk pregnancy on women undergoing antepartum hospitalization or home care, and discussed implications for health care professionals arising from the results of these studies. It is evident that high-risk pregnancy is very stressful for pregnant women and their families, irrespective of the setting of care. However, hospitalization seems to be associated with a greater number of stressors, the most predominant being separation from home and family. Wherever possible, health care professionals should strive to develop safe and acceptable alternatives to antepartum hospitalization.

Perceptions of bed rest by women with high-risk pregnancies: A comparison between home and hospital.

BACKGROUND: Bed rest at home or in the hospital is a commonly prescribed treatment for women experiencing complications of pregnancy. This focused ethnographic study examined bed rest from the high-risk pregnant woman's perspective and compared perceptions of women cared for in the home with those in hospital. METHODS: A convenience sample of 24 pregnant women who had been on bed rest for at least seven days was recruited from the antepartum unit of a tertiary care hospital and from an antepartum home care program in western Canada. Data were collected in 1994 through interviews and participant diaries. Content analysis was used to identify themes. RESULTS: Bed rest had a significant emotional and social impact on pregnant women and their families in both settings. Overall, bed rest in hospital seemed to be associated with more sources of stress than at home. In hospital, women had to cope with separation from home and family, lack of privacy, hospital discomforts, and incompatible roommates, whereas women at home struggled with role reversal and the temptation to do more activity than was recommended. Stressors not unique to but exacerbated by hospitalization included concerns about the children, a sense of missing out, a sense of confinement and being a prisoner, boredom, feelings of depression and loneliness, and negative impact on the relationship with their partner. CONCLUSION: Study findings raise questions about the appropriateness of routine prescription of bed rest. Health care professionals should propose and develop home care programs as an alternative to antepartum hospitalization.

Is a healthy lifestyle related to stress, parenting confidence, and health symptoms among new fathers?

A healthy lifestyle is widely recognized as important in preventing disease and disability. This study examined whether in the transition to fatherhood a healthy lifestyle was related to perceived stress, parenting confidence, and physical health symptoms. Survey data from 87 fathers were examined for relationships between lifestyle, measured by 6 subscales of the Health Promoting Lifestyle Profile (HPLP), and perceived stress, parenting confidence, and health symptoms. In general, a healthier lifestyle, especially HPLP self-actualization and stress-management subscales, was related to less perceived stress, more parenting confidence, and fewer health symptoms. Higher HPLP nutrition and exercise scores were related to fewer health symptoms; higher exercise and seeking-interpersonal-support scores were related to higher parenting confidence. Also, higher social desirability scores, a confounding influence, were related to less perceived stress. The authors conclude that health-promotion behaviours may be an important personal resource in maintaining health and promoting well-being among new fathers.

Bed rest from the perspective of the high-risk pregnant woman.

OBJECTIVE: To describe the experience of prolonged bed rest from the perspective of women during high-risk pregnancies. DESIGN: A focused ethnographic study that used interviews, participant diaries, and field notes as data sources. SETTING: Participants were obtained from an acute-care hospital antepartum unit and an antepartum home care program. PARTICIPANTS: Twenty-four women with complications of pregnancy requiring prolonged bed rest (range, 7-50 days). RESULTS: A model of the stress process in pregnant women on bed rest emerged from the data analysis. Stressors were grouped into situational (sick role, lack of control, uncertainty, concerns regarding fetus's well-being, and being tired of waiting), environmental (feeling like a prisoner, being bored, and having a sense of missing out), and family (role reversal and worry about older children) categories. Two main mediators of stress were social support and coping. Families, friends, and professionals were perceived as sources of support. Women used coping strategies, such as keeping a positive attitude, taking it 1 day at a time, doing it for the baby, getting used to it, setting goals, and keeping busy. Manifestations of stress were evidenced by adverse physical symptoms, emotional reactions, and altered social relationships. CONCLUSIONS: Prolonged bed rest is a stressful experience for pregnant women at high risk. Understanding the stress process in pregnant women confined to bed rest may assist nurses in developing interventions to reduce stressors and enhance mediators.

Patient satisfaction with an antepartum home-care program.

Evaluation of patient satisfaction with alternative health-care delivery models is an important component of program evaluation. Patient satisfaction occurs when there is congruence between expected care and the care received. This descriptive study investigated patient satisfaction with the Antepartum Home Care Program in Winnipeg, Canada. A convenience sample of 66 pregnant women completed the Antepartum Home Care Program Evaluation Questionnaire. Most respondents were very satisfied with the physical and emotional care they received at home, including the information they received. Ninety-eight percent of the women indicated that the care they received from the program met their expectations. Being able to receive care at home, rather than in the hospital, was the most frequently identified benefit of the Antepartum Home Care Program. These results will assist program planners with decisions concerning program improvements and growth.

Learning needs of hospitalized women at risk for preterm birth.

In this descriptive study, the priority learning needs of hospitalized women at risk of preterm birth were examined. A convenience sample of 34 pregnant women completed the Preterm Birth Learning Needs Questionnaire (PBLNQ). Respondents rated 18 teaching topics on a continuum from "not very important to know" to "very important to know." The topics rated as most important were the consequences of prematurity for the baby and problems of the newborn associated with preterm birth. Responses to open-ended questions validated mothers' overwhelming concerns for the welfare of their unborn children. The emotional crisis precipitated by hospitalization for possible preterm delivery changes the focus of teaching for those at risk of preterm birth and presents a particular challenge to those providing patient education.

Community-based home-care program for the management of pre-eclampsia: an alternative.

OBJECTIVE: To evaluate the safety, acceptability and cost of a community-based home-care program for the management of mild pre-eclampsia. DESIGN: A descriptive study of outcomes between Apr. 1, 1985, and Dec. 31, 1989. SETTING: St. Boniface General Hospital, Winnipeg. PATIENTS: Urban Winnipeg residents between 27 and 40 weeks' gestation with mild pre-eclampsia who demonstrated acceptance and compliance with home-care management; 321 patients of 1330 were enrolled in the program. INTERVENTIONS: Bed rest at home with daily biochemical and biophysical follow-up protocol and weekly clinic visits; patient education; hospital admission for labour, induction, worsening pre-eclampsia or noncompliance with rest at home. OUTCOME MEASURES: Patterns of referral to the program; clinical, biochemical and biophysical profiles; incidence of severe complications; reduction in total hospital stay and cost analysis. RESULTS: As many women were referred from physicians' offices as were referred from the hospital's antepartum unit, the average gestational age at referral being 36 weeks. Most (205 [64%]) of the women were nulliparous. The average length of stay in the program was 11.5 days. The program's availability resulted in a reduction of 2 days (from 5.7 days to 3.7 days) on average in the length of hospital stay when analysed for all 1330 women with pre-eclampsia. Of the 321 patients in the program 137 (43%) were admitted to hospital for worsening pre-eclampsia; severe pre-eclampsia developed 4 days after admission in 9. No patient suffered eclampsia, disseminated intravascular coagulopathy, abruption or fetal loss related to pre-eclampsia while in the program. The estimated cost saving in the management of pre-eclampsia was over $700,000 over the study period. CONCLUSION: The community-based home-care program is a safe, feasible and less costly alternative to hospital admission in the management of mild pre-eclampsia.

A comparison of childbirth expectations in high-risk and low-risk pregnant women.

This study described and compared the childbirth expectations of high-risk and low-risk pregnant women and then examined the influence of anxiety, risk status, and childbirth preparation on these expectations. This descriptive correlational study employed a convenience sample of 75 high-risk nulliparas and 77 low-risk nulliparas. Results indicated that high-risk pregnant women had significantly less positive expectations for their childbirth experience than did low-risk pregnant women. In particular, high-risk pregnant women expected more medical intervention and more difficulty coping with pain during their labor and birth. For both groups of women, anxiety was negatively correlated with childbirth expectations, whereas childbirth preparation was positively correlated with childbirth expectations.

Psychosocial aspects of antepartum hospitalization.

High-risk pregnant women who undergo antepartum hospitalization experience significant stress. Nurses play an important role in helping these pregnant women adapt to their high-risk status and cope effectively with hospitalization. This article identifies the stressors imposed by antepartum hospitalization and discusses nursing interventions to reduce the impact of those stressors.