Neighborhood Income Mobility and Risk of Neonatal and Maternal Morbidity.

Importance: Residing in a low-income neighborhood is generally associated with worse pregnancy outcomes. It is not known if moving from a low- to higher-income area between 2 pregnancies alters the risk of adverse birth outcomes in the subsequent birth compared with women who remain in low-income areas for both births. Objective: To compare the risk of adverse maternal and newborn outcomes among women who achieved upward area-level income mobility vs those who did not. Design, Setting, and Participants: This population-based cohort study was completed in Ontario, Canada, from 2002 to 2019, where there is universal health care. Included were all nulliparous women with a first-time singleton birth at 20 to 42 weeks' gestation, each residing in a low-income urban neighborhood at the time of the first birth. All women were then assessed at their second birth. Statistical analysis was conducted from August 2022 to April 2023. Exposure: Movement from a lowest-income quintile (Q1) neighborhood to any higher-income quintile neighborhood (Q2-Q5) between the first and second birth. Main Outcomes and Measures: The maternal outcome was severe maternal morbidity or mortality (SMM-M) at the second birth hospitalization or up to 42 days post partum. The primary perinatal outcome was severe neonatal morbidity or mortality (SNM-M) within 27 days of the second birth. Relative risks (aRR) and absolute risk differences (aARD) were estimated by adjusting for maternal and infant characteristics. Results: A total of 42 208 (44.1%) women (mean [SD] age at second birth, 30.0 [5.2] years) experienced upward area-level income mobility, and 53 409 (55.9%) women (age at second birth, 29.0 [5.4] years) remained in income Q1 between births. Relative to women who remained in income Q1 between births, those with upward mobility had a lower associated risk of SMM-M (12.0 vs 13.3 per 1000 births), with an aRR of 0.86 (95% CI, 0.78 to 0.93) and aARD of -2.09 per 1000 (95% CI, -3.1 to -0.9 per 1000 ). Likewise, their newborns experienced lower respective rates of SNM-M (48.0 vs 50.9 per 1000 live births), with an aRR of 0.91 (95% CI, 0.87 to 0.95) and aARD of -4.7 per 1000 (95% CI, -6.8 to -2.6 per 1000). Conclusions and Relevance: In this cohort study of nulliparous women living in low-income areas, those who moved to a higher-income area between births experienced less morbidity and death in their second pregnancy, as did their newborns, compared with those who remained in low-income areas between births. Research is needed to determine whether financial incentives or enhancement of neighborhood factors can reduce adverse maternal and perinatal outcomes.

Morbidity and mortality of newborns born to immigrant and nonimmigrant females residing in low-income neighbourhoods.

BACKGROUND: Living in low-income neighbourhoods and being an immigrant are each independently associated with adverse neonatal outcomes, but it is unknown if disparities exist in the neonatal period for children of immigrant and nonimmigrant females living in low-income areas. We sought to compare the risk of severe neonatal morbidity and mortality (SNMM) between newborns of immigrant and nonimmigrant mothers who resided in low-income neighbourhoods. METHODS: This population-based cohort study used administrative data for females residing in low-income urban neighbourhoods in Ontario, who had an in-hospital, singleton live birth at 20-42 weeks' gestation, from 2002 to 2019. We defined immigrant status as nonrefugee immigrant or nonimmigrant, further detailed by country of birth and duration of residence in Ontario. The primary outcome was a SNMM composite (with 16 diagnoses, including neonatal death and 7 neonatal procedures as indicators), arising within 0-27 days after birth. We estimated relative risks (RRs) and 95% confidence intervals (CIs) using modified Poisson regression with generalized estimating equations. RESULTS: Our cohort included 148 050 and 266 191 live births among immigrant and nonimmigrant mothers, respectively. Compared with newborns of non-immigrant females, SNMM was less frequent among newborns of immigrant females (49.7 v. 65.6 per 1000 live births), with an adjusted RR of 0.76 (95% CI 0.74 to 0.79). The most frequent SNMM indicator was receipt of ventilatory support. Relative to neonates of nonimmigrant females, the risk of SNMM was highest among those of immigrants from Jamaica (adjusted RR 1.14, 95% CI 1.05 to 1.23) and Ghana (adjusted RR 1.20, 95% CI 1.05 to 1.38), and lowest among those of immigrants from China (adjusted RR 0.44, 95% CI 0.40 to 0.48). Among immigrants, the risk of SNMM declined with shorter duration of residence before the index birth. INTERPRETATION: Within low-income urban areas, newborns of immigrant females had an overall lower risk of SNMM than those of nonimmigrant females, with considerable variation by maternal birthplace and duration of residence. Initiatives should focus on improving preconception health and perinatal care within subgroups of females residing in low-income neighbourhoods.

Severe Maternal Morbidity and Mortality Among Immigrant and Canadian-Born Women Residing Within Low-Income Neighborhoods in Ontario, Canada.

Importance: Evidence indicates that immigrant women and women residing within low-income neighborhoods experience higher adversity during pregnancy. Little is known about the comparative risk of severe maternal morbidity or mortality (SMM-M) among immigrant vs nonimmigrant women living in low-income areas. Objective: To compare the risk of SMM-M between immigrant and nonimmigrant women residing exclusively within low-income neighborhoods in Ontario, Canada. Design, Setting, and Participants: This population-based cohort study used administrative data for Ontario, Canada, from April 1, 2002, to December 31, 2019. Included were all 414 337 hospital-based singleton live births and stillbirths occurring between 20 and 42 weeks' gestation, solely among women residing in an urban neighborhood of the lowest income quintile; all women were receiving universal health care insurance. Statistical analysis was performed from December 2021 to March 2022. Exposures: Nonrefugee immigrant status vs nonimmigrant status. Main Outcomes and Measures: The primary outcome, SMM-M, was a composite outcome of potentially life-threatening complications or mortality occurring within 42 days of the index birth hospitalization. A secondary outcome was SMM severity, approximated by the number of SMM indicators (0, 1, 2 or ≥3 indicators). Relative risks (RRs), absolute risk differences (ARDs), and odds ratios (ORs) were adjusted for maternal age and parity. Results: The cohort included 148 085 births to immigrant women (mean [SD] age at index birth, 30.6 [5.2] years) and 266 252 births to nonimmigrant women (mean [SD] age at index birth, 27.9 [5.9] years). Most immigrant women originated from South Asia (52 447 [35.4%]) and the East Asia and Pacific (35 280 [23.8%]) regions. The most frequent SMM indicators were postpartum hemorrhage with red blood cell transfusion, intensive care unit admission, and puerperal sepsis. The rate of SMM-M was lower among immigrant women (2459 of 148 085 [16.6 per 1000 births]) than nonimmigrant women (4563 of 266 252 [17.1 per 1000 births]), equivalent to an adjusted RR of 0.92 (95% CI, 0.88-0.97) and an adjusted ARD of -1.5 per 1000 births (95% CI, -2.3 to -0.7). Comparing immigrant vs nonimmigrant women, the adjusted OR of having 1 SMM indicator was 0.92 (95% CI, 0.87-0.98), the adjusted OR of having 2 indicators was 0.86 (95% CI, 0.76-0.98), and the adjusted OR of having 3 or more indicators was 1.02 (95% CI, 0.87-1.19). Conclusions and Relevance: This study suggests that, among universally insured women residing in low-income urban areas, immigrant women have a slightly lower associated risk of SMM-M than their nonimmigrant counterparts. Efforts aimed at improving pregnancy care should focus on all women residing in low-income neighborhoods.

Neighbourhood Income and Risk of Having an Infant With Concomitant Preterm Birth and Severe Small for Gestational Age Birth Weight.

OBJECTIVE: Socioeconomic position gradients have been individually demonstrated for preterm birth (PTB) at <37 weeks gestation and severe small for gestational age birth weight at <5th percentile (SGA). It is not known how neighbourhood income is related to the combination of PTB and severe SGA, a state reflective of greater placental dysfunction and higher risk of neonatal morbidity and mortality than PTB or severe SGA alone. METHODS: This population-based study comprised all 1 367 656 singleton live births in Ontario from 2002 to 2011. Multinomial logistic regression was used to estimate the odds of PTB with severe SGA, PTB without severe SGA, and severe SGA without PTB, compared with neither PTB nor severe SGA, in relation to neighbourhood income quintile (Q). The highest income quintile, Q5, served as the exposure referent. Adjusted odds ratios (aORs) were adjusted for maternal age at delivery, parity, marital status, and world region of birth (Canadian Task Force Classification II-2). RESULTS: Relative to women residing in Q5 (2.3 per 1000), the rate of PTB with severe SGA was highest among those in Q1 (3.6 per 1000), with an aOR of 1.34 (95% confidence interval [CI] 1.20-1.50). The corresponding aORs were 1.23 (95% CI 1.09-1.37) for Q2, 1.14 (95% CI 1.02-1.28) for Q3, and 1.06 (95% CI 0.95-1.20) for Q4. Less pronounced aORs were seen for each individual outcome of PTB and severe SGA. CONCLUSION: Women residing in the lowest-income areas are at highest risk of having a fetus born too small and too soon. Future research should focus on identifying those women most predisposed to combined PTB and severe SGA.

Breastfeeding to 12 mo and beyond: nutrition outcomes at 3 to 5 y of age.

Background: Little is known about nutrition outcomes in preschoolers associated with breastfeeding duration beyond 12 mo of age. Objective: The aim was to examine the association between total breastfeeding duration and nutrition outcomes at 3 to 5 y of age. Design: A cross-sectional study in healthy children, ages 3-5 y, recruited from 9 primary care practices in Toronto was conducted through the TARGet Kids! (The Applied Research Group for Kids) research network. Parents completed standardized surveys, including the Nutrition Screening for Every Preschooler (NutriSTEP) used to assess nutrition risk. Results: A total of 2987 children were included. Ninety-two percent of children were breastfed, and the mean ± SD breastfeeding duration was 11.4 ± 8.4 mo. The prevalence of nutrition risk (score >20) was 17.0%. We examined breastfeeding duration as a continuous variable. With the use of restricted cubic spline modeling, we confirmed a nonlinear relation between breastfeeding duration and NutriSTEP score, dietary intake and eating behavior subscores, and sugar-sweetened beverage and sweet-savory snack consumption. Segmented linear regression was used to examine this nonlinear relation in a piecewise approach. We found a decreasing trend in NutriSTEP score for children who were breastfed for 0-6 mo (ß = -0.14; 95% CI: -0.29, 0.004), a significant decrease in NutriSTEP score for children breastfed for 6-12 mo (ß = -0.20; 95% CI: -0.33, -0.07), and no significant change after 12 mo (ß = 0.09; 95% CI: -0.07, 0.24) and beyond. The mean ± SD NutriSTEP scores were 17.1 ± 7.4 for no breastfeeding, 15.9 ± 6.5 for breastfeeding >0-6 mo, 13.9 ± 6.2 for >6-12 mo, 13.7 ± 6.3 for >12-18 mo, 14.6 ± 6.7 for >18-24 mo, and 14.3 ± 6.8 for >24-36 mo. Conclusions: Breastfeeding for ≤12 mo was associated with decreased nutrition risk and healthier eating behaviors and dietary intake at 3-5 y of age. We found insufficient evidence of additional benefit for breastfeeding beyond 12 mo of age. The TARGet Kids! practice-based research network is registered at www.clinicaltrials.gov as NCT01869530.

Ethnic Differences in Visceral Adiposity Measured in Early Pregnancy.

OBJECTIVE: To determine if visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) depth in early pregnancy differs by maternal ethnicity. METHODS: We prospectively evaluated 482 women without pre-pregnancy diabetes. All underwent sonographic measurement of VAT and SAT depth at 11 to 14 weeks' gestation. RESULTS: SAT did not differ between groups, but VAT did. Compared with Canadian-born women (3.9 cm, 95% CI 3.7-4.1), mean VAT depth was higher among Latin American (4.6 cm, 95% CI 4.1-5.2), Sub-Saharan African (5.0 cm, 95% CI 4.0-6.1), and Caribbean (6.0 cm, 95% CI 4.8-7.3) women. Adjusting for age, parity, and 1/height2, the relative risks of having a VAT depth >80th percentile were 1.69 (95% CI 1.05-2.73) for Latin American, 2.24 (95% CI 1.28-3.93) for Sub-Saharan African, and 3.34 (95% CI 1.91-5.84) for Caribbean women, relative to Canadian-born women. Women from these world regions also had a greater percentage of preterm births and emergency CSs. CONCLUSION: VAT differs appreciably among certain ethnic groups, which may reflect their predisposition to adverse pregnancy outcomes.

Concomitant preterm birth and severe small-for-gestational age birth weight among infants of immigrant mothers in Ontario originating from the Philippines and East Asia: a population-based study.

OBJECTIVES: Women from the Philippines form one of the largest immigrant groups to North America. Their newborns experience higher rates of preterm birth (PTB), and separately, small-for-gestational age (SGA) birth weight, compared with other East Asians. It is not known if Filipino women are at elevated risk of concomitant PTB and severe SGA (PTB-SGA), a pathological state likely reflective of placental dysfunction and neonatal morbidity. METHODS: We conducted a population-based study of all singleton or twin live births in Ontario, from 2002 to 2011, among immigrant mothers from the Philippines (n=27 946), Vietnam (n=15 297), Hong Kong (n=5618), South Korea (n=5148) and China (n=42 517). We used modified Poisson regression to generate relative risks (RR) of PTB-SGA, defined as a birth <37 weeks' gestation and a birth weight <5th percentile. RRs were adjusted for maternal age, parity, marital status, income quintile, infant sex and twin births. RESULTS: Relative to mothers from China (2.3 per 1000), the rate of PTB-SGA was significantly higher among infants of mothers from the Philippines (6.5 per 1000; RR 2.91, 95% CI 2.27 to 3.73), and those from Vietnam (3.7 per 1000; RR 1.68, 95% CI 1.21 to 2.34). The RR of PTB-SGA was not higher for infants of mothers from Hong Kong or South Korea. INTERPRETATION: Among infants born to immigrant women from five East Asian birthplaces, the risk of PTB-SGA was highest among those from the Philippines. These women and their fetuses may require additional monitoring and interventions.

Potential cost-effectiveness of supervised injection facilities in Toronto and Ottawa, Canada.

BACKGROUND AND AIMS: Supervised injection facilities (legally sanctioned spaces for supervised consumption of illicitly obtained drugs) are controversial public health interventions. We determined the optimal number of facilities in two Canadian cities using health economic methods. DESIGN: Dynamic compartmental model of HIV and hepatitis C transmission through sexual contact and sharing of drug use equipment. SETTING: Toronto and Ottawa, Canada. PARTICIPANTS: Simulated population of each city. INTERVENTIONS: Zero to five supervised injection facilities. MEASUREMENTS: Direct health-care costs and quality-adjusted life-years (QALYs) over 20 years, discounted at 5% per year; incremental cost-effectiveness ratios. FINDINGS: In Toronto, one facility cost $4.1 million and resulted in a gain of 385 QALYs over 20 years, for an incremental cost-effectiveness ratio (ICER) of $10,763 per QALY [95% credible interval (95CrI): cost-saving to $278,311]. Establishing one facility in Ottawa had an ICER of $6127 per QALY (95CrI: cost-saving to $179,272). At a $50,000 per QALY threshold, three facilities would be cost-effective in Toronto and two in Ottawa. The probability that establishing three, four, or five facilities in Toronto was cost-effective was 17, 21, and 41%, respectively. Establishing one, two, or three facilities in Ottawa was cost-effective with 13, 35, and 41% probability, respectively. Establishing no facility was unlikely to be the most cost-effective option (14% in Toronto and 10% in Ottawa). In both cities, results were robust if the reduction in needle-sharing among clients of the facilities was at least 50% and fixed operating costs were less than $2.0 million. CONCLUSIONS: Using a $50,000 per quality-adjusted life-years threshold for cost-effectiveness, it is likely to be cost-effective to establish at least three legally sanctioned spaces for supervised injection of illicitly obtained drugs in Toronto, Canada and two in Ottawa, Canada.

Increasing public support for supervised injection facilities in Ontario, Canada.

AIM: To determine the level and changes in public opinion between 2003 and 2009 among adult Canadians about implementation of supervised injection facilities (SIFs) in Canada. DESIGN: Population-based, telephone survey data collected in 2003 and 2009 were analysed to identify strong, weak, and intermediate support for SIFs. SETTING: Ontario, Canada PARTICIPANTS: Representative samples of adults aged 18 years and over. MEASUREMENTS: Analyses of the agreement with implementation of SIFs in relation to four individual SIF goals and a composite measure. FINDINGS: The final sample sizes for 2003 and 2009 were 1212 and 968, respectively. Between 2003 and 2009, there were increases in the proportion of participants who strongly agreed with implementing SIFs to: reduce neighbourhood problems (0.309 versus 0.556, respectively); increase contact of people who use drugs with health and social workers (0.257 versus 0.479, respectively); reduce overdose deaths or infectious disease among people who use drugs (0.269 versus 0.482, respectively); and encourage safer drug injection (0.213 versus 0.310, respectively). Analyses using a composite measure of agreement across goals showed that 0.776 of participants had mixed opinions about SIFs in 2003, compared with only 0.616 in 2009. There was little change among those who strongly disagreed with all SIF goals (0.091 versus 0.113 in 2003 and 2009, respectively). CONCLUSIONS: Support for implementation of supervised injection facilities in Ontario, Canada increased between 2003 and 2009, but at both time-points a majority still held mixed opinions.

Design considerations for supervised consumption facilities (SCFs): preferences for facilities where people can inject and smoke drugs.

BACKGROUND: Supervised consumption facilities (SCFs) aim to improve the health and well-being of people who use drugs by offering safer and more hygienic alternatives to the risk environments where people typically use drugs in the community. People who smoke crack cocaine may be willing to use supervised smoking facilities (SSFs), but their facility design preferences and the views of other stakeholders have not been previously investigated in detail. METHODS: We consulted with people who use drugs and other stakeholders including police, fire and ambulance service personnel, other city employees and city officials, healthcare providers, residents, and business owners (N = 236) in two Canadian cities without SCFs and asked how facilities ought to be designed. All consultations were audio-recorded and transcribed. Thematic analyses were used to describe the knowledge and opinions of stakeholders. RESULTS: People who use drugs see SSFs as offering public health and safety benefits, while other stakeholders were more sceptical about the need for SSFs. People who use drugs provided insights into how a facility might be designed to accommodate supervised injection and supervised smoking. Their strongest preference would allow both methods of drug use within the same facility with some form of physical separation between the two based on different highs, comfort regarding exposure to different methods of drug administration, and concerns about behaviours often associated with smoking crack cocaine. Other stakeholders raised a number of SSF implementation challenges worthy of consideration. CONCLUSION: Decision-makers in cities considering SCF or SSF implementation should consider the opinions and preferences of potential clients to ensure that facilities will attract, retain, and engage people who use drugs.

Sexual health, risk behaviors, and substance use in heterosexual-identified women with female sex partners: 2002 US National Survey of Family Growth.

BACKGROUND: Despite knowledge that some people engage in same-sex sexuality without espousing a sexual minority identity, this has rarely been studied in women. METHODS: Heterosexual women aged 20 to 44 who indicated one or more female sex partners in the past year were compared to those with less recent female sex partners, and to bisexual, homosexual, and exclusively heterosexual women using 2002 US National Survey of Family Growth data. RESULTS: Compared to exclusively heterosexual women, heterosexual women with a past-year female sex partner were significantly more likely to smoke tobacco (46% vs. 19%), binge drink (34% vs. 11%), use marijuana (58% vs. 11%), and use cocaine (19% vs. 2%). Substance use was high in this group overall, but they did not differ significantly from bisexuals on tobacco use or from homosexual or bisexual women on regular alcohol consumption. Most heterosexual women with a past-year female sex partner had only one in their lifetime. They had 10 median lifetime male partners versus 1 to 7 for other groups. Whereas similar to heterosexual women with less recent female sex partners and to bisexual women on some sexual risk measures, these women were more likely than any other group to have had a non-monogamous male partner (40%) or to have engaged in sex while high (69%). Differences in sexual risk and substance use were not explained by demographic differences. CONCLUSIONS: Results suggest same-sex behavior in heterosexual-identified women is a marker for a substance use and sexual risk profile distinct from that of bisexual, lesbian, or exclusively heterosexual women.

Are lesbians really women who have sex with women (WSW)? Methodological concerns in measuring sexual orientation in health research.

Varying measures of sexual orientation are used in women's health research. As they incorporate different dimensions, definitions, and categorical groupings, the comparability of results obtained across studies using different measures remains unknown. We examined the comparability of results using data from the U.S. 2002 National Survey of Family Growth (n = 6,356). Women were classified according to sexual orientation identity, sex of sex partners in the past year, and sex of sex partners over the lifetime. Associations with six health outcomes were compared across sexual orientation schemes. Associations differed in magnitude and statistical significance, even producing conflicting results. Our analyses resulted in a series of methodological recommendations for research on sexual minority women. Data on both behavioral and identity measures should be gathered in health research; identity groups should not be combined for analysis; and researchers should carefully consider which classification scheme(s) to use based on the theoretical basis for the study and the implications for informing interventions.