Resources available for parent-provider vaccine communication in pregnancy in Canada: a scoping review.

OBJECTIVE: Vaccination in pregnancy (VIP) is a protective measure for pregnant individuals and their babies. Healthcare provider's (HCP) recommendations are important in promoting VIP. However, a lack of strong recommendations and accessible resources to facilitate communication impact uptake. This study sought to determine the extent of and characterise the resources available for parent-provider vaccine communication in pregnancy in Canada using a behavioural theory-informed approach. DESIGN: Scoping review. METHODS: In accordance with the JBI methodology, nine disciplinary and interdisciplinary databases were searched, and a systematic grey literature search was conducted in March and January 2022, respectively. Eligible studies included resources available to HCPs practising in Canada when discussing VIP, and resources tailored to pregnant individuals. Two reviewers piloted a representative sample of published and grey literature using inclusion-exclusion criteria and the Authority, Accuracy, Coverage, Objectivity, Date, Significance guidelines (for grey literature only). Sixty-five published articles and 1079 grey reports were screened for eligibility, of which 19 articles and 166 reports were included, respectively. RESULTS: From the 19 published literature articles and 166 grey literature reports, 95% were driven by the 'Knowledge' domain of the Theoretical Domains Framework, while n=34 (18%) addressed the 'Skills' domain. Other gaps included a lack of VIP-specific tools to address hesitancy and a lack of information on culturally safe counselling practices. CONCLUSION: The study suggests a need for resources in Canada to improve VIP communication skills and improve access to vaccination information for HCPs and pregnant individuals. The absence of such resources may hinder VIP uptake.

Very-low-birth-weight infant short-term post-discharge outcomes: A retrospective study of specialized compared to standard care.

OBJECTIVE: Ongoing health care challenges, low breast milk intake, and the need for rehospitalization are common during the first year of life after hospital discharge for very low birth weight (VLBW) infants. This retrospective cohort study examined breast milk intake, growth, emergency department (ED) visits, and non-surgical rehospitalizations for VLBW infants who received specialized post-discharge follow-up in western Canada, compared to VLBW infants who received standard follow-up in central Canada. DESIGN: Data were collected from two neonatal follow-up programs for VLBW babies (n = 150 specialized-care; n = 205 standard-care). Logistic regression was used to examine odds of breast milk intake and generalized estimating equations were used for odds of growth, ED visits and non-surgical rehospitalization by site. RESULTS: Specialized-care was associated with enhanced breast milk intake duration; the odds of receiving breastmilk at 4 months in the specialized-care cohort was 6 times that in the standard-care cohort. The specialized-care cohort had significantly more ED visits and rehospitalizations. However, for infants with oxygen use beyond 36 weeks compared to those with no oxygen use, the standard-care cohort had over 7 times the odds of rehospitalization where as the specialized-care cohort with no increased odds of rehospitalization. CONCLUSION: Specialized neonatal nursing follow-up was associated with continued breastmilk intake beyond discharge. Infants in the specialized-care cohort used the ED and were hospitalized more often than the standard-care cohort with the exception of infants with long term oxygen needs.

Fluoridation cessation and oral health equity: a 7-year post-cessation study of Grade 2 schoolchildren in Alberta, Canada.

OBJECTIVE: Community water fluoridation, because of its universal scope and passive mechanism of uptake, is one component of a multifaceted approach to promoting equity in dental health. The objective of this study was to examine social inequities in children's dental health in the Canadian cities of Calgary (fluoridation cessation in 2011) and Edmonton (still fluoridated). METHODS: We analyzed data from surveys of population-based samples of Grade 2 (approx. age 7) children in Calgary in 2009/2010 (pre-cessation; n=557) and in both Calgary and Edmonton in 2013/2014 (Calgary, n=3230; Edmonton, n=2304) and 2018/2019 (Calgary, n=2649; Edmonton, n=2600) (post-cessation). We estimated associations between several socioeconomic indicators and dental caries indicators (i.e., dental caries experience [deft, DMFT] and untreated decay in two or more teeth [untreated decay]) using zero-inflated Poisson, binary logistic regression, and the concentration index of inequality. We compared those associations over time (between survey waves) and between cities at post-cessation. RESULTS: Persistent social inequities in deft and untreated decay were evident; for example, having no dental insurance was significantly associated with higher odds of untreated decay across city and survey wave. In most (but not all) cases, differences between cities and survey waves were consistent with an adverse effect of fluoridation cessation on dental health inequities. For example, the association between no dental insurance and higher odds of untreated decay in Calgary was greater in 2018/2019 (later post-cessation) than in 2009/2010 (pre-cessation; odds ratio [OR] for comparison of coefficients = 1.89 [1.36-2.63], p<0.001) and 2013/2014 (early post-cessation; OR for comparison of coefficients = 1.67 [1.22-2.28], p=0.001); that same association in 2018/2019 was greater in Calgary (fluoridation cessation) than in Edmonton (still fluoridated) (OR for comparison of coefficients = 1.44 [1.03-2.02], p=0.033). CONCLUSION: Social inequities in dental caries were present in both Calgary and Edmonton. Those inequities tended to be worse in Calgary where fluoridation was ceased. Our findings may be relevant to other settings where income inequality is high, dental services are costly, and dental public health infrastructure is limited.

RéSUMé: OBJECTIF: En raison de sa portée universelle et de son mécanisme de réception passif, la fluoration de l'eau des communautés s'inscrit dans une démarche multidimensionnelle de promotion de l'équité en santé dentaire. Notre étude visait à examiner les iniquités sociales en santé dentaire chez les enfants dans les villes canadiennes de Calgary (où la fluoration a cessé en 2011) et d'Edmonton (où l'eau est encore enrichie en fluor). MéTHODE: Nous avons analysé les données d'enquêtes menées auprès d'échantillons populationnels d'élèves de 2e année (environ 7 ans) à Calgary en 2009-2010 (avant l'arrêt; n = 557), et à Calgary et Edmonton en 2013-2014 (Calgary, n = 3 230; Edmonton, n = 2 304) et en 2018-2019 (Calgary, n = 2 649; Edmonton, n = 2 600) (après l'arrêt). Nous avons estimé les associations entre plusieurs indicateurs socioéconomiques et indicateurs de caries dentaires (c.-à-d. l'expérience de caries dentaires [dceo, DCMO] et de dégradation non traitée dans deux dents ou plus [dégradation non traitée]) à l'aide de la régression de Poisson à surreprésentation de zéros, de la régression logistique binaire et de l'indice de concentration des inégalités. Nous avons comparé ces associations dans le temps (entre les cycles de l'enquête) et entre les deux villes après l'arrêt de la fluoration. RéSULTATS: Des iniquités sociales persistantes selon l'indice dceo [dents cariées, extraites et obturées] et la dégradation non traitée étaient manifestes; par exemple, l'absence d'assurance dentaire présentait une corrélation significative avec une probabilité accrue de dégradation non traitée d'une ville à l'autre et d'un cycle à l'autre de l'enquête. Dans la plupart des cas (mais pas tous), les différences entre les villes et entre les cycles de l'enquête correspondaient à un effet indésirable de l'arrêt de la fluoration sur les iniquités en santé dentaire. Par exemple, l'association entre l'absence d'assurance dentaire et la probabilité accrue de dégradation non traitée à Calgary était plus importante en 2018-2019 (longtemps après l'arrêt) qu'en 2009-2010 (avant l'arrêt; rapport de cotes [RC] pour comparaison des coefficients = 1,89 [1,36-2,63], p < 0,001) et qu'en 2013-2014 (peu après l'arrêt; RC pour comparaison des coefficients = 1,67 [1,22-2,28], p = 0,001); cette même association en 2018-2019 était plus importante à Calgary (où la fluoration a cessé) qu'à Edmonton (où l'eau est encore enrichie en fluor) (RC pour comparaison des coefficients = 1,44 [1,03-2,02], p = 0,033). CONCLUSION: Des iniquités sociales relativement aux caries dentaires étaient présentes tant à Calgary qu'à Edmonton. Ces iniquités avaient tendance à être plus importantes à Calgary, où la fluoration a cessé. Nos constatations pourraient être pertinentes dans les autres endroits où l'inégalité des revenus est élevée, où les soins dentaires coûtent cher et où les infrastructures en santé publique dentaire sont limitées.

Feasibility and Acceptability of Internet-Based Interpersonal Psychotherapy for Stress, Anxiety, and Depression in Prenatal Women: Thematic Analysis.

BACKGROUND: Prenatal mental health is a global health concern. Despite the far-reaching impact of prenatal mental health issues, many women do not receive the psychological care they require. Women in their childbearing years are frequent users of the internet and smartphone apps. Prenatal women are prime candidates for internet-based support for mental health care. OBJECTIVE: This study aimed to examine the feasibility and acceptability of internet-based interpersonal psychotherapy (IPT) for prenatal women. METHODS: Semistructured interviews were conducted with women who had received internet-based IPT modules with guided support as a component of a randomized controlled trial evaluating the scale-up implementation of a digital mental health platform (The Healthy Outcomes of Pregnancy and Postpartum Experiences digital platform) for pregnant women. Qualitative thematic analysis was used to explore and describe women's experiences. Data were analyzed for emerging themes, which were identified and coded. RESULTS: A total of 15 prenatal women were interviewed to examine their experiences and views on the feasibility and acceptability of internet-based IPT modules. Participants found the content informative and appreciated the ways in which the digital mental health platform made the IPT modules accessible to users. Participants voiced some differing requirements regarding the depth and the way information was presented and accessed on the digital mental health platform. The important areas for improvement that were identified were acknowledging greater depth and clarity of content, the need for sociability and relationships, and refinement of the digital mental health platform to a smartphone app. CONCLUSIONS: This study provides useful evidence regarding treatment format and content preferences, which may inform future development. It also provides research data on the feasibility and acceptability of web-based applications for prenatal mental health care. TRIAL REGISTRATION: ClinicalTrials.gov NCT01901796; https://clinicaltrials.gov/ct2/show/NCT01901796.

Facilitators and barriers to implementation of Alberta family integrated care (FICare) in level II neonatal intensive care units: a qualitative process evaluation substudy of a multicentre cluster-randomised controlled trial using the consolidated framework for implementation research.

OBJECTIVE: To evaluate the barriers and facilitators to implementing Alberta Family Integrated Care (AB-FICare [2019 Benzies]), a model of care for integrating parents into level II neonatal intensive care units (NICUs) care teams, from the perspective of healthcare providers (HCP) and hospital administrators. DESIGN: Qualitative process evaluation substudy. SETTING: Ten level II NICUs in six cities across Alberta, Canada. PARTICIPANTS: HCP and hospital administrators (n=32) who were involved in the cluster-randomised controlled trial of AB-FICare in level II NICUs. METHODS: Post-implementation semi-structured interviews were conducted via phone or in-person. The Consolidated Framework for Implementation Research was used to develop interview guides, code transcripts and analyse data. RESULTS: Key facilitators to implementation of AB-FICare included (1) a receptive implementation climate, (2) compatibility of the intervention with individual and organisational practices, (3) available resources and access to knowledge and information for HCP and hospital administrators, (4) engagement of key stakeholders across the organisation, (5) engagement of and outcomes for intervention participants, and (6) reflecting and evaluating on implementation progress and patient and family outcomes. Barriers were (1) design quality and packaging of the intervention, (2) relative priority of AB-FICare in relation to other initiatives, and (3) learning climate within the organisation. Mixed influences on implementation depending on contextual factors were coded to eight constructs: intervention source, cost, peer pressure, external policy and incentives, staff needs and resources, structural characteristics, organisational incentives and rewards, and knowledge, beliefs and attitudes. CONCLUSIONS: The characteristics of an organisation and the implementation process had largely positive influences, which can be leveraged for implementation of AB-FICare in the NICU. We recommend site-specific consultations to mitigate barriers and assess how swing factors might impact implementation given the local context, with the goal that strategies can be put in place to manage their influence on implementation. TRIAL REGISTRATION NUMBER: NCT02879799.

Opportunistic postpartum depression symptom screening at well-child clinics in Alberta, 2012-2016.

OBJECTIVES: The study objective was to assess the reach and delivery of opportunistic postpartum depression (PPD) symptom screening at well-child clinic (WCC) immunization appointments in Alberta. The relationship between socio-demographic factors and PPD symptom screening status, and PPD symptom scores was explored. METHOD: In this retrospective population-based cohort study, administrative health data from WCC immunization appointments were used to assess the PPD symptom screening delivery and scores from January 1, 2012 to December 31, 2016. The associations with maternal age and area-level material deprivation were determined by multivariable statistics. RESULTS: The number of births ranged from 51,537 to 55,787 annually. The percentage of mothers screened for PPD symptoms using the Edinburgh Postnatal Depression Scale decreased between 2012 and 2016, from 80.1% to 69.7%. Of those screened, 3-3.2% of the mothers were identified to be at high risk for PPD, annually. Screening status varied according to maternal age: mothers ≤29 years were more likely to be screened than mothers 30-34 years, while mothers ≥35 years were the least likely to be screened. Logistic regression analyses, adjusting for age, found the odds of not being screened increased with increases in area-level material deprivation. Language/cultural barriers were the most commonly reported reasons for not screening. CONCLUSION: Opportunistic PPD symptom screening at WCCs can be an efficient method to identify mothers who need postpartum support and to inform population-level public health surveillance. Additional work is needed to further understand barriers to PPD symptom screening, especially language, cultural, and socio-demographic factors.

RéSUMé: OBJECTIFS: Évaluer la portée et l'exécution du dépistage opportuniste des symptômes de dépression du post-partum (DPP) lors des visites d'immunisation en clinique du bien-être de l'enfant (CBEE) en Alberta. Nous avons exploré la relation entre les facteurs sociodémographiques et la situation à l'égard du dépistage des symptômes de DPP, ainsi que les pointages des symptômes de DPP. MéTHODE: Pour cette étude de cohorte populationnelle rétrospective, nous avons utilisé les données administratives sur la santé des visites d'immunisation en CBEE pour évaluer l'exécution et les pointages du dépistage des symptômes de DPP entre le 1er janvier 2012 et le 31 décembre 2016. Les associations avec l'âge maternel et la défavorisation matérielle régionale ont été déterminées par analyses statistiques multivariées. RéSULTATS: Le nombre de naissances variait entre 51 537 et 55 787 par année. Le pourcentage de mères dépistées pour les symptômes de DPP à l'aide de l'échelle de dépression postnatale d'Édimbourg a diminué sur la période de l'étude, passant de 80,1 % en 2012 à 69,7 % en 2016. Parmi les mères dépistées, 3 à 3,2 % par année ont été identifiées comme présentant un risque élevé de DPP. La situation à l'égard du dépistage variait selon l'âge maternel : les mères de 29 ans et moins étaient plus susceptibles d'être dépistées que celles de 30 à 34 ans, et les mères de 35 ans et plus étaient les moins susceptibles d'être dépistées. Des analyses de régression logistique, après ajustement pour tenir compte de l'âge, ont déterminé que la probabilité de ne pas être dépistée augmentait avec l'augmentation de la défavorisation matérielle régionale. Les barrières linguistiques ou culturelles ont été les raisons les plus communément citées de ne pas avoir réalisé de dépistage. CONCLUSION: Le dépistage opportuniste des symptômes de DPP dans les CBEE peut être un moyen efficace d'identifier les mères ayant besoin d'un soutien post-partum et d'orienter la surveillance de la santé publique à l'échelle de la population. D'autres études sont nécessaires pour mieux comprendre les barrières au dépistage des symptômes de DPP, en particulier les facteurs linguistiques, culturels et sociodémographiques.

Maximizing maternal health and value for money in postpartum depression screening: a cost-effectiveness analysis using the All Our Families cohort and administrative data in Alberta, Canada.

BACKGROUND: Postpartum depression (PPD) affects 10-15% of women, is costly and debilitating, yet often remains undiagnosed. Within Alberta, Canada, screening is conducted at public health well child clinics using the Edinburgh Postnatal Depression Scale. If screened high-risk, women are offered referral to their family physicians for follow up diagnosis and treatment. METHODS: We developed a decision tree to estimate the cost-effectiveness of PPD screening versus not screening in Alberta over a two-year time horizon using a public healthcare payer perspective. Both the current practice (51% attending referral) and a scenario analysis (100% attending referral) are presented. RESULTS: Current practice results suggest screening leads to an incremental cost-effectiveness ratio (ICER) of $17,644 USD per quality adjusted life year (QALY). At a population-level, this resulted in an annual 813 (11%) additional cases diagnosed, 120 additional QALYs gained, and an additional cost of $2.1 million relative to not screening. With 100% attending referral, the ICER fell to $13,908 per QALY, resulting in an annual 1997 (27%) additional cases diagnosed, 249 additional QALYs gained, and an additional cost of $3.5 million relative to not screening. LIMITATIONS: We were unable to explore the cost-effectiveness of PPD screening versus not screening for secondary populations, including children. CONCLUSIONS: The results suggest screening may be most valuable when participation and compliance are maximized, where all women screened high-risk attend referral. This leads to greater value for money and increased maternal health gains across the population. Collaboration among public health and primary care services is encouraged to improve outcomes.

Vitamin D supplementation to improve pregnancy and perinatal outcomes: an overview of 42 systematic reviews.

OBJECTIVE: To review the evidence to assess effectiveness of vitamin D supplementation during pregnancy and associations of serum vitamin D levels with perinatal outcomes. DESIGN: Overview of systematic reviews (SRs). DATA SOURCES: Searches conducted in January 2019: Ovid Medline (1946-), Cochrane Library databases. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Two reviewers independently screened titles and abstracts, and full texts using predefined inclusion criteria: SRs evaluating vitamin D supplementation in pregnant women and/or examining the association between serum vitamin D levels reporting at least one predefined perinatal outcome. Only SRs with high AMSTAR scores were analysed. DATA EXTRACTION AND SYNTHESIS: Data were extracted independently by one reviewer and checked by a second. Results were assessed for quality independently by two reviewers using GRADE criteria. RESULTS: Thirteen SRs were included, synthesising evidence from 204 unique primary studies. SRs of randomised controlled trials (RCTs) with the highest level of evidence showed no significant benefit from vitamin D in terms of preterm birth (RR 1.00 (95% CI 0.77, 1.30); high quality), pre-eclampsia (RR 0.91 (0.45, 1.86); low quality), gestational diabetes (RR 0.65 (0.39, 1.08); very low quality), stillbirth (RR 0.75 (0.50, 1.12); high quality), low birth weight (RR 0.74 (0.47, 1.16); low quality), caesarean section (RR 1.02 (0.93, 1.12); high quality). A significant difference was found for small for gestational age (RR 0.72 (0.52, 0.99); low quality). SRs of observational studies showed associations between vitamin D levels and preterm birth (RR 1.19 (1.08, 1.31); moderate quality), pre-eclampsia (RR 1.57 (1.21, 2.03) for 25-hydroxy vitamin D (25 (OH)D)<50 nmol/L subgroup; low quality), gestational diabetes (RR 1.12 (1.02, 1.22) for 25 (OH)D<50 nmol/L and RR 1.09 (1.03, 1.15)<75 nmol/L; moderate quality) and small for gestational age (RR 1.35 (1.18, 1.54)<50 nmol/L; low quality). SRs showed mixed results for associations between vitamin D and low birth weight (very low quality) and caesarean section (very low quality). CONCLUSION: There is some evidence from SRs of observational studies for associations between vitamin D serum levels and some outcomes; however SRs examining effectiveness from RCTs showed no effect of vitamin D supplementation in pregnancy with the exception of one predefined outcome, which had low quality evidence. Credibility of the evidence in this field is compromised by study limitations (in particular, the possibility of confounding among observational studies), inconsistency, imprecision and potential for reporting and publication biases.

Examining postpartum depression screening effectiveness in well child clinics in Alberta, Canada: A study using the All Our Families cohort and administrative data.

Affecting 10-15% of women, postpartum depression (PPD) can be debilitating and costly. While early identification has the potential to improve timely care, recommendations regarding the implementation of routine screening are inconsistent. In Alberta, screening is completed using the Edinburgh Postnatal Depression Scale during public health well child clinic visits. The objective of this study was to examine the effectiveness of screening in identifying, diagnosing and treating women at increased risk for PPD over the first year postpartum, compared to those unscreened. The All Our Families prospective pregnancy cohort was linked to public health, inpatient, outpatient, physician claims and community pharmaceutical data over the first year postpartum. Descriptive statistics and bivariate analyses examined differences in sample characteristics and PPD and non-PPD related utilization by screening category. Odds ratios and 95% confidence intervals for PPD diagnosis and mental health drugs dispensed were generated using crude and multivariable logistic regression models. Within our sample, 87% of the eligible population were screened, with 3% receiving a high-risk score, and 13% were unscreened. Compared to those unscreened, women screened high-risk had higher odds of being diagnosed with PPD (OR: 3.88, 95% CI: 2.18-6.92) and women screened low/moderate-risk had reduced odds of receiving a diagnosis (OR: 0.51, 95% CI: 0.35-0.74). High-risk women had an increased likelihood of diagnosis, higher PPD-related utilization and drugs dispensed compared to those unscreened. This information suggests that screening was effective at streamlining resources in Alberta. Future work should focus on evaluating the cost-effectiveness of PPD screening.

Maternal perceptions of childhood vaccination: explanations of reasons for and against vaccination.

BACKGROUND: Understanding reasons for and against vaccination from the parental perspective is critical for designing vaccination campaigns and informing other interventions to increase vaccination uptake in Canada. The objective of this study was to understand maternal vaccination decision making for children. METHODS: Mothers participating in a longitudinal community-based pregnancy cohort, the All Our Babies study in Calgary, Alberta, completed open-ended survey questions providing explanations for the vaccination status of their child by 24 months postpartum. Qualitative responses were linked to administrative vaccination records to examine survey responses and recorded child vaccination status. RESULTS: There were 1560 open-ended responses available; 89% (n = 1391) provided explanations for vaccinating their children, 5% (n = 79) provided explanations for not vaccinating/delaying, and 6% (n = 90) provided explanations for both. Themes were similar for those vaccinating and not vaccinating/delaying; however, interpretations were different. Two broad themes were identified: Sources of influence and Deliberative Processes. Sources of influence on decision making included personal, family, and external experiences. Deliberative Processes included risk, research, effectiveness, and balancing risks/benefits. Under Deliberative Processes, responsibility was a category for those vaccinating; while choice, instrumental/practical, and health issues were categories for those not vaccinating/delaying. Mothers' levels of conviction and motivation provided a Context for understanding their decision making perspectives. CONCLUSIONS: Vaccination decision making is complex and impacted by many factors that are similar but contribute to different decisions depending on mothers' perspectives. The results of this study indicate the need to examine new intervention approaches to increase uptake that recognize and address feelings of pressure and parental commitment to choice.

Internet-based interpersonal psychotherapy for stress, anxiety, and depression in prenatal women: study protocol for a pilot randomized controlled trial.

BACKGROUND: Psychological distress, defined as depression, anxiety and perceived stress, during pregnancy is common, with 15-25% of women experiencing clinically significant levels of such distress. Despite the far-reaching impact of prenatal psychological distress on mothers and their children, and that women are receptive to screening, few providers routinely screen for prenatal psychological distress and less than one in five women will receive the mental health care that they require. There is a lack of certainty regarding the most effective treatments for prenatal psychological distress. No online interpersonal psychotherapy (IPT) trials have been conducted that focus on improving psychological distress in prenatal women. The purpose of this pilot randomized controlled trial is to evaluate the perspectives of pregnant women on the feasibility and acceptability of online IPT (e-IPT) delivered during pregnancy. METHODS: A pilot randomized controlled trial design with repeated measures will evaluate the feasibility and acceptability of e-IPT for pregnant women compared to routine prenatal care. Qualitative interviews with 15-30 individuals in the intervention group will provide further data on the feasibility and acceptability of the intervention. Assessment of feasibility will include the ease of accessing and completing the intervention. Women will also be asked about what barriers there were to starting and completing the e-IPT. Assessment of acceptability will inquire about the perception of women regarding the intervention and its various features. A sample size of 160 consenting pregnant women aged 18 years and older will be enrolled and randomized into the experimental (e-IPT) or control (routine care) condition. The secondary outcome measures include: depression, anxiety and stress symptoms; self-efficacy; self-mastery; self-esteem; relationship quality (spouse, immediate family members); coping; and resilience. All participants will complete the aforementioned measures at baseline during pregnancy (T1), 3 months postrandomization (T2), at 8 months of pregnancy (T3), and 3 months postpartum (T4). DISCUSSION: The results of this pilot randomized controlled trial will provide data on the feasibility and acceptability of the intervention and identify necessary adaptations. This study will allow for optimization of full trial processes and inform the evaluation strategy, including sample size calculations for the full randomized controlled trial. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01901796. Registered on 18 December 2014.

Differences in caesarean rates across women's socio-economic status by diverse obstetric indications: Cross-sectional study.

BACKGROUND: The existing inconsistent association between the caesarean rate and maternal socio-economic status (SES) may be the result of a failure to examine the association across indications for caesarean. This study examined the variation in caesarean rates by maternal SES across diverse obstetric-indications. METHODS: Data on demographics, education, insurance status, medical-conditions, and obstetric characteristics needed to classify deliveries according to Robson's 10 obstetric-groups were extracted from the 2015 US birth certificate data (n = 3 988 733). Multivariable log-binomial regression was used to analyse the data adjusting for confounders. RESULTS: The caesarean rate was 34.1% for women with high SES and 26.8% for those with low SES. After adjustment for confounders, the rate was similar between women with graduate degrees and those who did not complete high school (relative risk (RR) 1.0, 95% confidence interval (CI) 0.9, 1.1). However, different rates of caesareans across SES were observed for particular obstetric-indications. Notably, women with graduate education compared to those who did not complete high school were more likely to have a caesarean (RR 3.0, 95% CI 2.9, 3.1) for a low-risk condition (group 1: nulliparous women with single, cephalic, ≥37 gestational weeks, and spontaneous labour). Women with private insurance were more likely to have a caesarean in almost all obstetric groups, compared to those without private insurance or Medicaid. CONCLUSION: Examining the overall caesarean rate obscures the relationship between SES and the use of caesarean for particular obstetric-indications. The unequal utilisation of caesareans across SES highlights overuse and potential underuse of the caesareans among American women.

Ethnic disparities in children's oral health: findings from a population-based survey of grade 1 and 2 schoolchildren in Alberta, Canada.

BACKGROUND: Although oral health has improved remarkably in recent decades, not all populations have benefited equally. Ethnic identity, and in particular visible minority status, has been identified as an important risk factor for poor oral health. Canadian research on ethnic disparities in oral health is extremely limited. The aim of this study was to examine ethnic disparities in oral health outcomes and to assess the extent to which ethnic disparities could be accounted for by demographic, socioeconomic and caries-related behavioral factors, among a population-based sample of grade 1 and 2 schoolchildren (age range: 5-8 years) in Alberta, Canada. METHODS: A dental survey (administered during 2013-14) included a mouth examination and parent questionnaire. Oral health outcomes included: 1) percentage of children with dental caries; 2) number of decayed, extracted/missing (due to caries) and filled teeth; 3) percentage of children with two or more teeth with untreated caries; and 4) percentage of children with parental-ratings of fair or poor oral health. We used multivariable regression analysis to examine ethnic disparities in oral health, adjusting for demographic, socioeconomic and caries-related behavioral variables. RESULTS: We observed significant ethnic disparities in children's oral health. Most visible minority groups, particularly Filipino and Arab, as well as Indigenous children, were more likely to have worse oral health than White populations. In particular, Filipino children had an almost 5-fold higher odds of having severe untreated dental problems (2 or more teeth with untreated caries) than White children. Adjustment for demographic, socioeconomic, and caries-related behavior variables attenuated but did not eliminate ethnic disparities in oral health, with the exception of Latin American children whose outcomes did not differ significantly from White populations after adjustment. CONCLUSIONS: Significant ethnic disparities in oral health exist in Alberta, Canada, even when adjusting for demographic, socioeconomic and caries-related behavioral factors, with Filipino, Arab, and Indigenous children being the most affected.

A qualitative inquiry on pregnant women's preferences for mental health screening.

BACKGROUND: Approaches to screening can influence the acceptance of and comfort with mental health screening. Qualitative evidence on pregnant women's comfort with different screening approaches and disclosure of mental health concerns is scant. The purpose of this study was to understand women's perspectives of different mental health screening approaches and the perceived barriers to the communication and disclosure of their mental health concerns during pregnancy. METHODS: A qualitative descriptive study was undertaken. Fifteen women, with a singleton pregnancy, were recruited from a community maternity clinic and a mental health clinic in Calgary, Canada. Semi-structured interviews were conducted during both the 2nd and 3rd trimesters. Data were analyzed using thematic analysis. RESULTS: Preferences for mental health screening approaches varied. Most women with a known mental health issue preferred a communicative approach, while women without a known mental health history who struggled with emotional problems were inclined towards less interactive approaches and reported a reluctance to share their concerns. Barriers to communicating mental health concerns included a lack of emotional literacy (i.e., not recognizing the symptoms, not understanding the emotions), fear of disclosure outcomes (i.e., fear of being judged, fear of the consequences), feeling uncomfortable to be seen vulnerable, perception about the role of prenatal care provider (internal barriers); the lack of continuity of care, depersonalized care, lack of feedback, and unfamiliarity with/uncertainty about the availability of support (structural barriers). CONCLUSIONS: The overlaps between some themes identified for the reasons behind a preferred screening approach and barriers reported by women to communicate mental health concerns suggest that having options may help women overcome some of the current disclosure barriers and enable them to engage in the process. Furthermore, the continuity of care, clarity around the outcomes of disclosing mental health concerns, and availability of immediate support can help women move from providing "the best answer" to providing an authentic answer.

Timeliness and completeness of routine childhood vaccinations in children by two years of age in Alberta, Canada.

OBJECTIVES: Assessing timeliness and completeness of vaccine administration is important for evaluating the effectiveness of immunization programs. Few studies have reported timeliness, particularly in Canada. The objective of this study was to examine timeliness of the receipt of vaccination for each routine childhood recommended vaccine by 24 months of age among children in a community-based pregnancy cohort in Calgary, Alberta. METHODS: Survey data from a community-based pregnancy cohort in Alberta were linked to Public Health vaccination records of children (n = 2763). The proportion of children receiving early, timely, delayed, or no vaccination was calculated. A dose was considered early if it was administered before the recommended age in days as per the vaccination schedule, timely if administered at any time from start of recommended age in days to age in days when delay counts were initiated, and delayed if it was administered on or after age in days when delay counts were initiated. Series completion rates were also calculated. RESULTS: For multi-dose vaccines, over 80% of children had timely doses at 2, 4 and 6 months. By 12 months, this proportion decreased to 65% (95% CI: 63%-66%) for meningococcal conjugate group C, 61% (95% CI: 59%-62%) for measles antigen-containing vaccines and 64% (95% CI: 62%-65%) for varicella antigen-containing vaccines. At 18 months, only 55% (95% CI: 53%-56%) of the children had a timely 4th dose of diphtheria, acellular pertussis, tetanus, polio, and Haemophilus influenzae type b vaccine. Eventual series completion rate for all recommended vaccines was 77% (95% CI: 75%-79%). CONCLUSION: The timeliness and completeness of routine childhood vaccination in preschool children in this community-based pregnancy cohort is lower than provincial targets. Data on timeliness of vaccination can inform further work on barriers and enablers to vaccination in order to meet provincial targets.

The New Parent Checklist: A Tool to Promote Parental Reflection.

PURPOSE: To design and establish content and face validity of an evidence-informed tool that promotes parental self-reflection during the transition to parenthood. STUDY DESIGN AND METHODS: The New Parent Checklist was developed using a three-phase sequential approach: Phase 1 a scoping review and expert consultation to develop and refine a prototype tool; Phase 2 content analysis of parent focus groups; and Phase 3 assessment of utility in a cross-sectional sample of parents completing the New Parent Checklist and a questionnaire. RESULTS: The initial version of the checklist was considered by experts to contain key information. Focus group participants found it useful, appropriate, and nonjudgmental, and offered suggestions to enhance readability, utility, as well as face and content validity. In the cross-sectional survey, 83% of the participants rated the New Parent Checklist as "helpful" or "very helpful" and 90% found the New Parent Checklist "very easy" to use. Open-ended survey responses included predominantly positive feedback. Notable differences existed for some items based on respondents' first language, age, and sex. Results and feedback from all three phases informed the current version, available for download online. CLINICAL IMPLICATIONS: The New Parent Checklist is a comprehensive evidence-informed self-reflective tool with promising content and face validity. Depending on parental characteristics and infant age, certain items of the New Parent Checklist have particular utility but may also require further adaptation and testing. Local resources for information and/or support are included in the tool and could be easily adapted by other regions to incorporate their own local resources.

Invested in Success: A Qualitative Study of the Experience of CenteringPregnancy Group Prenatal Care for Perinatal Educators.

The objective of this study was to understand the central meaning of the experience of providing CenteringPregnancy for perinatal educators who were facilitators for the group sessions. Four perinatal educators participated in one-on-one interviews and/or a validation focus group. Six themes emerged: (a) "stepping back and taking on a different role," (b) "supporting transformation," (c) "getting to knowing," (d) "working together to bridge the gap," (e) "creating the environment," and (f) "fostering community." These themes contributed to the core phenomenon of being "invested in success." Through bridging gaps and inconsistencies in information received from educators and physicians, this model of CenteringPregnancy provides an opportunity for women to act on relevant information more fully than more traditional didactic approaches to perinatal education.

Equity in children's dental caries before and after cessation of community water fluoridation: differential impact by dental insurance status and geographic material deprivation.

BACKGROUND: One of the main arguments made in favor of community water fluoridation is that it is equitable in its impact on dental caries (i.e., helps to offset inequities in dental caries). Although an equitable effect of fluoridation has been demonstrated in cross-sectional studies, it has not been studied in the context of cessation of community water fluoridation (CWF). The objective of this study was to compare the socio-economic patterns of children's dental caries (tooth decay) in Calgary, Canada, in 2009/10 when CWF was in place, and in 2013/14, after it had been discontinued. METHODS: We analyzed data from population-based samples of schoolchildren (grade 2) in 2009/10 and 2013/14. Data on dental caries (decayed, missing, and filled primary and permanent teeth) were gathered via open mouth exams conducted in schools by registered dental hygienists. We examined the association between dental caries and 1) presence/absence of dental insurance and 2) small area index of material deprivation, using Poisson (zero-inflated) and logistic regression, for both time points separately. For small-area material deprivation at each time point, we also computed the concentration index of inequality for each outcome variable. RESULTS: Statistically significant inequities by dental insurance status and by small area material deprivation were more apparent in 2013/14 than in 2009/10. CONCLUSIONS: Results are consistent with increasing inequities in dental caries following cessation of CWF. However, further research is needed to 1) confirm the effects in a study that includes a comparison community, and 2) explore possible alternative reasons for the findings, including changes in treatment and preventive programming.