Prevalence and clinical, social, and health care predictors of miscarriage.

BACKGROUND: Pregnancy loss is common and several factors (e.g. chromosomal anomalies, parental age) are known to increase the risk of occurrence. However, much existing research focuses on recurrent loss; comparatively little is known about the predictors of a first miscarriage. Our objective was to estimate the population-level prevalence of miscarriages and to assess the contributions of clinical, social, and health care use factors as predictors of the first detected occurrence of these losses. METHODS: In this population-based cohort study, we used linked administrative health data to estimate annual rates of miscarriage in the Manitoba population from 2003 to 2014, as a share of identified pregnancies. We compared the unadjusted associations between clinical, social, and health care use factors and first detected miscarriage compared with a live birth. We estimated multivariable generalized linear models to assess whether risk factors were associated with first detected miscarriage controlling for other predictors. RESULTS: We estimated an average annual miscarriage rate of 11.3%. In our final sample (n = 79,978 women), the fully-adjusted model indicated that use of infertility drugs was associated with a 4 percentage point higher risk of miscarriage (95% CI 0.02, 0.06) and a past suicide attempt with a 3 percentage point higher risk (95% CI -0.002, 0.07). Women with high morbidity were twice as likely to experience a miscarriage compared to women with low morbidity (RD = 0.12, 95% CI 0.09, 0.15). Women on income assistance had a 3 percentage point lower risk (95% CI -0.04, -0.02). CONCLUSIONS: We estimate that 1 in 9 pregnant women in Manitoba experience and seek care for a miscarriage. After adjusting for clinical factors, past health care use and morbidity contribute important additional information about the risk of first detected miscarriage. Social factors may also be informative.

Predictors of Women's Satisfaction with Prenatal Care in a Canadian Setting.

OBJECTIVE: Prenatal care is a vital and important part of a healthy pregnancy, providing many maternal and health benefits. Despite Canada's publically funded health care system with universal access, inadequate rates of prenatal care continue to be observed. As a modifiable risk factor, the process variables that influence satisfaction with prenatal care in Canadian settings have received little attention. The objective of this study was to identify the predictors of satisfaction with prenatal care. METHODS: A cross-sectional, descriptive, correlational design was used to examine the relationships between expectations, interpersonal processes of care, the quality of prenatal care, personal characteristics, and the type of provider with overall satisfaction, and with four dimensions of satisfaction. A convenience sample of 216 pregnant women was surveyed using self-administered questionnaires with women in their third trimester. Multiple linear regression analyses were used to identify predictors of satisfaction. RESULTS: The quality of prenatal care and provider interpersonal style together explained 80% of the variance in overall satisfaction. Patient-centered decision-making was a significant predictor of satisfaction with information, while having a midwife was a predictor of satisfaction with system characteristics. Expectations were not related to satisfaction. CONCLUSIONS FOR PRACTICE: Improving quality of care, provider interpersonal style and patient-centered decision making, and improving the structural characteristics of prenatal care may be effective in improving women's satisfaction and utilization of prenatal care.

The Association of Inadequate and Intensive Prenatal Care With Maternal, Fetal, and Infant Outcomes: A Population-Based Study in Manitoba, Canada.

OBJECTIVE: Little is known about how prenatal care influences health outcomes in Canada. The objective of this study was to examine the association of prenatal care utilization with maternal, fetal, and infant outcomes in Manitoba. METHODS: This retrospective cohort study conducted at the Manitoba Centre for Health Policy investigated all deliveries of singleton births from 2004-2005 to 2008-2009 (N = 67 076). The proportion of women receiving inadequate, intermediate/adequate, and intensive prenatal care was calculated. Multivariable logistic regression was used to examine the association of inadequate and intensive prenatal care with maternal and fetal-infant health outcomes, health care use, and maternal health-related behaviours. RESULTS: The distribution of prenatal care utilization was 11.6% inadequate, 84.4% intermediate/adequate, and 4.0% intensive. After adjusting for sociodemographic factors and maternal health conditions, inadequate prenatal care was associated with increased odds of stillbirth, preterm birth, low birth weight, small for gestational age (SGA), admission to the NICU, postpartum depressive/anxiety disorders, and short interpregnancy interval to next birth. Women with inadequate prenatal care had reduced odds of initiating breastfeeding or having their infant immunized. Intensive prenatal care was associated with reduced odds of stillbirth, preterm birth, and low birth weight and increased odds of postpartum depressive/anxiety disorders, initiation of breastfeeding, and infant immunization. CONCLUSION: Inadequate prenatal care was associated with increased odds of several adverse pregnancy outcomes and lower likelihood of health-related behaviours, whereas intensive prenatal care was associated with reduced odds of some adverse pregnancy outcomes and higher likelihood of health-related behaviours. Ensuring women receive adequate prenatal care may improve pregnancy outcomes.

Inequities in utilization of prenatal care: a population-based study in the Canadian province of Manitoba.

BACKGROUND: Ensuring high quality and equitable maternity services is important to promote positive pregnancy outcomes. Despite a universal health care system, previous research shows neighborhood-level inequities in utilization of prenatal care in Manitoba, Canada. The purpose of this population-based retrospective cohort study was to describe prenatal care utilization among women giving birth in Manitoba, and to determine individual-level factors associated with inadequate prenatal care. METHODS: We studied women giving birth in Manitoba from 2004/05-2008/09 using data from a repository of de-identified administrative databases at the Manitoba Centre for Health Policy. The proportion of women receiving inadequate prenatal care was calculated using a utilization index. Multivariable logistic regressions were used to identify factors associated with inadequate prenatal care for the population, and for a subset with more detailed risk information. RESULTS: Overall, 11.5% of women in Manitoba received inadequate, 51.0% intermediate, 33.3% adequate, and 4.1% intensive prenatal care (N = 68,132). Factors associated with inadequate prenatal care in the population-based model (N = 64,166) included northern or rural residence, young maternal age (at current and first birth), lone parent, parity 4 or more, short inter-pregnancy interval, receiving income assistance, and living in a low-income neighborhood. Medical conditions such as multiple birth, hypertensive disorders, antepartum hemorrhage, diabetes, and prenatal psychological distress were associated with lower odds of inadequate prenatal care. In the subset model (N = 55,048), the previous factors remained significant, with additional factors being maternal education less than high school, social isolation, and prenatal smoking, alcohol, and/or illicit drug use. CONCLUSION: The rate of inadequate prenatal care in Manitoba ranged from 10.5-12.5%, and increased significantly over the study period. Factors associated with inadequate prenatal care included geographic, demographic, socioeconomic, and pregnancy-related factors. Rates of inadequate prenatal care varied across geographic regions, indicating persistent inequities in use of prenatal care. Inadequate prenatal care was associated with several individual indicators of social disadvantage, such as low income, education less than high school, and social isolation. These findings can inform policy makers and program planners about regions and populations most at-risk for inadequate prenatal care and assist with development of initiatives to reduce inequities in utilization of prenatal care.

Examining Early Childhood Health Outcomes of Children Born Late Preterm in Urban Manitoba.

Objective The late preterm population [34-36 weeks gestational age (GA)] is known to incur increased morbidity in the infancy stage compared to the population born at term (39-41 weeks GA). This study aimed to examine the health of these children during their early childhood years, with specific attention to the role of socioeconomic status. Methods A retrospective cohort study was conducted using data from the Manitoba Centre for Health Policy, including all live-born children born at 34-36 and 39-41 weeks GA in urban Manitoba between 2000 and 2005 (n = 28,100). Multivariable logistic regression was used to examine the association of GA with early childhood morbidity after controlling for maternal, child and family level variables. Results The late preterm population was found to have significantly greater adjusted odds of lower respiratory tract infections in the preschool years (aOR = 1.59 [1.24, 2.04]) and asthma at school age (aOR = 1.33 [1.18, 1.47]) compared to the population born at term. The groups also differed in health care utilization at ages 4 (aOR = 1.19 [1.06,1.34]) and 7 years (aOR = 1.24 [1.09, 1.42]). Additional variables associated with poor outcomes suggest that social deprivation and GA simultaneously have a negative impact on early childhood development. Conclusions for Practice Adjustment for predictors of poor early childhood development, including socioeconomic status, were found to attenuate but not eliminate health differences between children born late preterm and children born at term. Poorer health outcomes that extend into childhood have implications for practice at the population level and suggest a need for further follow-up post discharge.

Partner Disengagement from Pregnancy and Adverse Maternal and Infant Outcomes.

OBJECTIVE: To assess whether partner disengagement from pregnancy is associated with adverse maternal and infant outcomes. MATERIALS AND METHODS: We analyzed data from the 2006-2007 Canadian Maternity Experiences Survey, comprising a cross-sectional representative sample of 6,421 childbearing women. Multiple logistic regression assessed the association between adverse outcomes and three indicators of partner disengagement: (1) partner did not want the pregnancy, (2) partner argued more than usual in the year prior to the baby's birth, and (3) partner was absent at the delivery. RESULTS: Of all respondents, 3.8% had partners who did not want the pregnancy, 16.1% argued more than usual with their partner in the past year, and 7.6% had partners who were absent at the delivery. Women whose partner did not want the pregnancy were more likely to report intimate partner violence (IPV) (adjusted odds ratio [AOR] 3.55; 95% confidence interval [95% CI] 2.36-5.14), elevated depressive symptoms in the extended postpartum period (AOR 2.56, 95% CI 1.70-3.83), and nonroutine child healthcare visits after birth (AOR 1.54, 95% CI 1.13-2.11). Women whose partner argued more in the past year had higher odds of IPV (AOR 4.82, 95% CI 3.69-6.30), elevated depressive symptoms in the extended postpartum period (AOR 3.63; 95% CI 2.84-4.64), and nonroutine child healthcare visits (AOR 1.49, 95% CI 1.26-1.77), after adjustment for potential confounders. CONCLUSIONS: Partner disengagement is common and is associated with adverse maternal and infant outcomes. Affected women may benefit from special assistance during pregnancy and after delivery.

Choosing an out-of-hospital birth centre: Exploring women's decision-making experiences.

OBJECTIVE: the primary objective for this study was to explore women's experiences of choosing to plan a birth at an out-of-hospital birth centre. We sought to understand how women make the choice to plan for an out-of-hospital birth and the meaning that women ascribe to this decision-making process. DESIGN, SETTING, AND PARTICIPANTS: a qualitative phenomenological study was conducted in Winnipeg, Canada with a sample of seventeen post partum women who represent the socio-demographic characteristics of the actual users of the Birth Centre in Winnipeg. The women participated in semistructured interviews. Through a feminist perspective and using interpretative phenomenological analysis (IPA), each participant's experience of birthplace decision-making was explored. FINDINGS: six themes emerged through the analysis: (1) Making the decision in the context of relationships; (2) Exercising personal agency; (3) An expression of one's ideology; (4) Really thinking it through; (5) Fitting into the eligibility criteria; and (6) The psychology of the space. The findings suggested that a woman's sense of safety was related to each of these themes. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the birth centre decision-making experience has many similarities to the homebirth decision-making process. The visceral impact of the physical design of the facility plays an important role and differentiates the birth centre decision from other birth setting options. The concept of relational autonomy was emphasised in this study, in that women make the decision in the context of their relationships with their midwives and partners. The study has implications for midwifery practice and health-care policy related to: client education on birth settings, design of birth environments, validation of the birth centre concept, and upholding the women-centred midwifery model of care. The study highlighted the importance of increasing access to out-of-hospital birth centres.

Factors Associated With High Levels of Perceived Prenatal Stress Among Inner-City Women.

OBJECTIVE: To explore the factors associated with high rates of perceived prenatal stress among inner-city women. DESIGN: Observational cross-sectional study. SETTING/PARTICIPANTS: We conducted a secondary analysis of data from 603 inner-city women. In our study, 330 participants (54.7%) self-identified as First Nations, Metis, or First Nations/Metis. METHODS: Prenatal stress was measured with Cohen's Perceived Stress Scale. A social ecological model provided the theoretical framework for the study, and variables representing all levels of the model were selected for study. Data analyses included t tests to compare women with high stress and low/moderate stress, univariable logistic regression analysis to determine the association of selected factors with maternal stress, and multivariable logistic regression analysis to provide adjusted odds ratios and 95% confidence intervals for the factors. RESULTS: Of the 603 participants, 17.2% (104) reported high levels of perceived stress, and 82.8% (499) reported low/moderate levels. The high-stress group included a significantly greater proportion of First Nations, Metis, or First Nations/Metis women (76.0%) than the low/moderate-stress group (50.3%). Low rates of self-esteem and social support, residential mobility, abuse before/during pregnancy, and experiencing discrimination were significantly associated with high levels of perceived prenatal stress. CONCLUSION: Our findings demonstrated that factors that influence prenatal stress occur at all levels of the social ecological model. The identified factors are amenable to change, and implications for practice include the need for psychosocial risk assessment, alternative forms of prenatal care, relational care, and advocacy initiatives. A greater understanding of the complex factors associated with high rates of perceived prenatal stress can inform the development of effective interventions for inner-city women.

Disclosure during prenatal mental health screening.

BACKGROUND: While women and healthcare providers have generally viewed perinatal mental health screening favorably, some qualitative studies suggest that some women intentionally decide not to reveal their symptoms during screening. PURPOSE: The purpose of this study was to describe women's reported willingness to disclose mental health concerns during screening and factors associated with this. METHODS: This cross-sectional study included pregnant women who were >16 years of age and could speak/read English. Women were recruited from five maternity clinics and two community hospitals in Alberta, Canada (May-December, 2013). Eligible women completed the online Barriers and Facilitators of Mental Health Screening Questionnaire on recruitment. The primary outcome for this analysis was women's level of honesty about mental health concerns (completely vs somewhat/not at all honest) during screening. Analyses included descriptive statistics and multivariable logistic regressions to identify factors associated with honesty. RESULTS: Participation rate was 92% (460/500). Seventy-nine percent of women indicated that they could be 'completely honest' during screening. Women who feared their provider would view them as bad mothers were less likely to be honest. We found a significant association between 'less anonymous' modes of screening and honesty. LIMITATIONS: Over eighty percent of women in this study were well-educated, partnered, Caucasian women. As such, generalizability of the study findings may be limited. CONCLUSIONS: Most women indicated they could be honest during screening. Stigma-related factors and screening mode influenced women's willingness to disclose. Strategies to reduce stigma during screening are warranted to enhance early detection of prenatal mental illness.

Preferences for Mental Health Screening Among Pregnant Women: A Cross-Sectional Study.

INTRODUCTION: The process of mental health screening can influence disclosure, uptake of referral, and treatment; however, no studies have explored pregnant women's views of methods of mental health screening. The objectives of this study are to determine pregnant women's comfort and preferences regarding mental health screening. METHODS: Pregnant women were recruited (May-December 2013) for this cross-sectional descriptive survey from prenatal classes and maternity clinics in Alberta, Canada, if they were aged >16 years and spoke/read English. Descriptive statistics summarized acceptability of screening, and multivariable logistic regression identified factors associated with women's comfort with screening methods. Analysis was conducted in January-December 2014. RESULTS: The participation rate was 92% (N=460/500). Overall, 97.6% of women reported that they were very (74.8%) or somewhat (22.8%) comfortable with mental health screening in pregnancy. Women were most comfortable with completing paper- (>90%) and computer-based (>82%) screening in a clinic or at home, with fewest reporting comfort with telephone-based screening (62%). The majority of women were very/somewhat comfortable with provider-initiated (97.4%) versus self-initiated (68.7%) approaches. Women's ability to be honest with their provider about emotional health was most strongly associated with comfort with each method of screening. CONCLUSIONS: The majority of pregnant women viewed prenatal mental health screening favorably and were comfortable with a variety of screening methods. These findings provide evidence of high acceptability of screening--a key criterion for implementation of universal screening--and suggest that providers can select from a variety of screening methods best suited for their clinical setting.

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.

Barriers and facilitators related to use of prenatal care by inner-city women: perceptions of health care providers.

BACKGROUND: Socioeconomic disparities in the use of prenatal care (PNC) exist even where care is universally available and publicly funded. Few studies have sought the perspectives of health care providers to understand and address this problem. The purpose of this study was to elicit the experiential knowledge of PNC providers in inner-city Winnipeg, Canada regarding their perceptions of the barriers and facilitators to PNC for the clients they serve and their suggestions on how PNC services might be improved to reduce disparities in utilization. METHODS: A descriptive exploratory qualitative design was used. Semi-structured interviews were conducted with 24 health care providers serving women in inner-city neighborhoods with high rates of inadequate PNC. Content analysis was used to code the interviews based on broad categories (barriers, facilitators, suggestions). Emerging themes and subthemes were then developed and revised through the use of comparative analysis. RESULTS: Many of the barriers identified related to personal challenges faced by inner-city women (e.g., child care, transportation, addictions, lack of support). Other barriers related to aspects of service provision: caregiver qualities (lack of time, negative behaviors), health system barriers (shortage of providers), and program/service characteristics (distance, long waits, short visits). Suggestions to improve care mirrored the facilitators identified and included ideas to make PNC more accessible and convenient, and more responsive to the complex needs of this population. CONCLUSIONS: The broad scope of our findings reflects a socio-ecological approach to understanding the many determinants that influence whether or not inner-city women use PNC services. A shift to community-based PNC supported by a multidisciplinary team and expanded midwifery services has potential to address many of the barriers identified in our study.

Perceptions of barriers, facilitators and motivators related to use of prenatal care: A qualitative descriptive study of inner-city women in Winnipeg, Canada.

OBJECTIVE: The objective of this qualitative descriptive study was to explore the perceptions of women living in inner-city Winnipeg, Canada, about barriers, facilitators, and motivators related to their use of prenatal care. METHODS: Individual, semi-structured interviews were conducted in person with 26 pregnant or postpartum women living in inner-city neighborhoods with high rates of inadequate prenatal care. Interviews averaged 67 min in length. Recruitment of participants continued until data saturation was achieved. Inductive content analysis was used to identify themes and subthemes under four broad topics of interest (barriers, facilitators, motivators, and suggestions). Sword's socio-ecological model of health services use provided the theoretical framework for the research. This model conceptualizes service use as a product of two interacting systems: the personal and situational attributes of potential users and the characteristics of health services. RESULTS: Half of the women in our sample were single and half self-identified as Aboriginal. Participants discussed several personal and system-related barriers affecting use of prenatal care, such as problems with transportation and child care, lack of prenatal care providers, and inaccessible services. Facilitating factors included transportation assistance, convenient location of services, positive care provider qualities, and tangible rewards. Women were motivated to attend prenatal care to gain knowledge and skills and to have a healthy baby. CONCLUSION: Consistent with the theoretical framework, women's utilization of prenatal care was a product of two interacting systems, with several barriers related to personal and situational factors affecting women's lives, while other barriers were related to problems with service delivery and the broader healthcare system. Overcoming barriers to prenatal care and capitalizing on factors that motivate women to seek prenatal care despite difficult living circumstances may help improve use of prenatal care by inner-city women.

Barriers, motivators and facilitators related to prenatal care utilization among inner-city women in Winnipeg, Canada: a case-control study.

BACKGROUND: The reasons why women do not obtain prenatal care even when it is available and accessible are complex. Despite Canada's universally funded health care system, use of prenatal care varies widely across neighborhoods in Winnipeg, Manitoba, with the highest rates of inadequate prenatal care found in eight inner-city neighborhoods. The purpose of this study was to identify barriers, motivators and facilitators related to use of prenatal care among women living in these inner-city neighborhoods. METHODS: We conducted a case-control study with 202 cases (inadequate prenatal care) and 406 controls (adequate prenatal care), frequency matched 1:2 by neighborhood. Women were recruited during their postpartum hospital stay, and were interviewed using a structured questionnaire. Stratified analyses of barriers and motivators associated with inadequate prenatal care were conducted, and the Mantel-Haenszel common odds ratio (OR) was reported when the results were homogeneous across neighborhoods. Chi square analysis was used to test for differences in proportions of cases and controls reporting facilitators that would have helped them get more prenatal care. RESULTS: Of the 39 barriers assessed, 35 significantly increased the odds of inadequate prenatal care for inner-city women. Psychosocial issues that increased the likelihood of inadequate prenatal care included being under stress, having family problems, feeling depressed, "not thinking straight", and being worried that the baby would be apprehended by the child welfare agency. Structural barriers included not knowing where to get prenatal care, having a long wait to get an appointment, and having problems with child care or transportation. Attitudinal barriers included not planning or knowing about the pregnancy, thinking of having an abortion, and believing they did not need prenatal care. Of the 10 motivators assessed, four had a protective effect, such as the desire to learn how to protect one's health. Receiving incentives and getting help with transportation and child care would have facilitated women's attendance at prenatal care visits. CONCLUSIONS: Several psychosocial, attitudinal, economic and structural barriers increased the likelihood of inadequate prenatal care for women living in socioeconomically disadvantaged neighborhoods. Removing barriers to prenatal care and capitalizing on factors that motivate and facilitate women to seek prenatal care despite the challenges of their personal circumstances may help improve use of prenatal care by inner-city women.

Quality of prenatal care questionnaire: instrument development and testing.

BACKGROUND: Utilization indices exist to measure quantity of prenatal care, but currently there is no published instrument to assess quality of prenatal care. The purpose of this study was to develop and test a new instrument, the Quality of Prenatal Care Questionnaire (QPCQ). METHODS: Data for this instrument development study were collected in five Canadian cities. Items for the QPCQ were generated through interviews with 40 pregnant women and 40 health care providers and a review of prenatal care guidelines, followed by assessment of content validity and rating of importance of items. The preliminary 100-item QPCQ was administered to 422 postpartum women to conduct item reduction using exploratory factor analysis. The final 46-item version of the QPCQ was then administered to another 422 postpartum women to establish its construct validity, and internal consistency and test-retest reliability. RESULTS: Exploratory factor analysis reduced the QPCQ to 46 items, factored into 6 subscales, which subsequently were validated by confirmatory factor analysis. Construct validity was also demonstrated using a hypothesis testing approach; there was a significant positive association between women's ratings of the quality of prenatal care and their satisfaction with care (r = 0.81). Convergent validity was demonstrated by a significant positive correlation (r = 0.63) between the "Support and Respect" subscale of the QPCQ and the "Respectfulness/Emotional Support" subscale of the Prenatal Interpersonal Processes of Care instrument. The overall QPCQ had acceptable internal consistency reliability (Cronbach's alpha = 0.96), as did each of the subscales. The test-retest reliability result (Intra-class correlation coefficient = 0.88) indicated stability of the instrument on repeat administration approximately one week later. Temporal stability testing confirmed that women's ratings of their quality of prenatal care did not change as a result of giving birth or between the early postpartum period and 4 to 6 weeks postpartum. CONCLUSION: The QPCQ is a valid and reliable instrument that will be useful in future research as an outcome measure to compare quality of care across geographic regions, populations, and service delivery models, and to assess the relationship between quality of care and maternal and infant health outcomes.

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.

Risk factors for postpartum depression among abused and nonabused women.

OBJECTIVE: The objective of the study was to compare risk factors for postpartum depression among women exposed vs not exposed to intimate partner violence and to assess the timing of abuse in relation to postpartum depression. STUDY DESIGN: This was a retrospective cohort study utilizing data from the Canadian Maternity Experiences Survey, a telephone survey at 5-10 months postpartum. Survey questions were adapted from the Canadian Violence Against Women Survey and the Edinburgh Post-Natal Depression Scale. RESULTS: Among abused women, younger (15-19 years), and older (35 years old and older), age was associated with postpartum depression, adjusted odds ratio (aOR, 2.29; 95% confidence interval [CI], 1.17-4.51) and (aOR, 2.33; 95% CI, 1.02-5.34) as was unemployment (aOR, 1.41; 95% CI, 1.06-1.84), foreign birth (aOR, 2.04; 95% CI, 1.35-3.09], and low income (aOR, 1.68; 95% CI, 1.25-2.25) among nonabused women. Postpartum depression was significantly associated with abuse occurring only prior to pregnancy (aOR, 3.28; 95% CI, 1.86-5.81), starting postpartum (aOR, 4.76; 95% CI, 1.41-16.02), and resuming postpartum (aOR, 3.81; 95% CI, 1.22-11.88). CONCLUSION: Among pregnant women, subgroups defined by abuse exposure differ in their risk profile for postpartum depression.

Women's and care providers' perspectives of quality prenatal care: a qualitative descriptive study.

BACKGROUND: Much attention has been given to the adequacy of prenatal care use in promoting healthy outcomes for women and their infants. Adequacy of use takes into account the timing of initiation of prenatal care and the number of visits. However, there is emerging evidence that the quality of prenatal care may be more important than adequacy of use. The purpose of our study was to explore women's and care providers' perspectives of quality prenatal care to inform the development of items for a new instrument, the Quality of Prenatal Care Questionnaire. We report on the derivation of themes resulting from this first step of questionnaire development. METHODS: A qualitative descriptive approach was used. Semi-structured interviews were conducted with 40 pregnant women and 40 prenatal care providers recruited from five urban centres across Canada. Data were analyzed using inductive open and then pattern coding. The final step of analysis used a deductive approach to assign the emergent themes to broader categories reflective of the study's conceptual framework. RESULTS: The three main categories informed by Donabedian's model of quality health care were structure of care, clinical care processes, and interpersonal care processes. Structure of care themes included access, physical setting, and staff and care provider characteristics. Themes under clinical care processes were health promotion and illness prevention, screening and assessment, information sharing, continuity of care, non-medicalization of pregnancy, and women-centredness. Interpersonal care processes themes were respectful attitude, emotional support, approachable interaction style, and taking time. A recurrent theme woven throughout the data reflected the importance of a meaningful relationship between a woman and her prenatal care provider that was characterized by trust. CONCLUSIONS: While certain aspects of structure of care were identified as being key dimensions of quality prenatal care, clinical and interpersonal care processes emerged as being most essential to quality care. These processes are important as they have a role in mitigating adverse outcomes, promoting involvement of women in their own care, and keeping women engaged in care. The findings suggest key considerations for the planning, delivery, and evaluation of prenatal care. Most notably, care should be woman-centred and embrace shared decision making as an essential element.

Revisiting the immigrant paradox in reproductive health: the roles of duration of residence and ethnicity.

The immigrant paradox refers to the contrasting observations that immigrants usually experience similar or better health outcomes than the native-born population despite socioeconomic disadvantage and barriers to health care use. This paradox, however, has not been examined simultaneously in relation to varying degrees of exposure to the receiving society and across multiple outcomes and risk factors. To advance knowledge on these issues, we analysed data of the Maternity Experiences Survey, a nationally representative cross-sectional survey of 6421 Canadian women who delivered singleton infants in 2006-07. We compared the prevalence of adverse pregnancy outcomes and related risk factors according to women's ethnicity and time since migration to Canada. We calculated prevalences and prevalence ratios (PR) with 95% confidence intervals. Compared to Canadian-born women of European descent, recent immigrants were at lower risk of preterm delivery and morbidity during pregnancy despite having the highest prevalence of low income and low support during pregnancy among all groups, but the paradox was not observed among immigrants with a longer stay in Canada. In contrast, recent immigrants were at higher risk of postpartum depression. Immigrants of non-European origin also had higher prevalence of postpartum depression, irrespective of their length of residence in Canada, but immigrants from European-origin countries did not. Exposure to Canada was also positively associated with higher alcohol and tobacco consumption and body mass index. Canadian-born women of non-European descent were at higher risk of preterm birth and hospitalisation during pregnancy than their European-origin counterparts. Our findings suggest that the healthy migrant hypothesis and the immigrant paradox have limited generalisability. These hypotheses may be better conceptualised as outcome-specific and dependent on immigrants' ethnicity and length of stay in the receiving country.

Experiences of violence before and during pregnancy and adverse pregnancy outcomes: an analysis of the Canadian Maternity Experiences Survey.

BACKGROUND: Abuse and violence against women constitute a global public health problem and are particularly important among women of reproductive age. The literature is not conclusive regarding the impact of violence against pregnant women on adverse pregnancy outcomes, such as preterm birth, small for gestational age and postpartum depression. Most studies have been conducted on relatively small samples of high-risk women. Our objective was to investigate what dimensions of violence against pregnant women were associated with preterm birth, small for gestational age and postpartum depression in a nationally representative sample of Canadian women. METHODS: We analysed data of the Maternity Experiences Survey, a nationally representative survey of Canadian women giving birth in 2006. The comprehensive questionnaire included a 19-item section to collect information on different dimensions of abuse and violence, such as type, frequency, timing and perpetrator of violence. The survey design is a stratified simple random sample from the 2006 Canadian Census sampling frame. Participants were 6,421 biological mothers (78% response rate) 15 years and older who gave birth to a singleton live birth and lived with their infant at the time of the survey. Logistic regression was used to compute Odds Ratios. Survey weights were used to obtain point estimates and 95% confidence intervals were obtained with the jacknife method of variance estimation. Covariate control was informed by use of directed acyclic graphs. RESULTS: No statistically significant associations were found for preterm birth or small for gestational age, after adjustment. Most dimensions of violence were associated with postpartum depression, particularly the combination of threats and physical violence starting before and continuing during pregnancy (Adjusted Odds Ratio = 4.1, 95% confidence interval: 1.9, 8.9) and perpetrated by the partner (4.3: 2.1, 8.7). CONCLUSIONS: Our findings provide weak evidence of an association between experiences of abuse before and during pregnancy and preterm birth and small for gestational age but they indicate that several dimensions of abuse and violence are consistently associated with postpartum depression.