Provincial variations in birth outcomes according to maternal country of birth, 2000 to 2016.

BACKGROUND: International migration is the main source of population growth in Canada. Research on the birth outcomes of immigrants has largely been based on Canadian provincial data, raising concerns about whether the findings can be generalized between provinces or between the provinces and Canada. Provincial time trends and variations in birth outcomes are described according to the 20 top maternal birthplaces. DATA AND METHODS: Statistics Canada's Vital Statistics-Birth Database (2000 to 2016) was used to extract 5,831,580 records on live births for analyses. Rates of preterm birth (PTB, referring to births at 22 to 36 gestation weeks) and mean birth weight (at 39 to 40 gestation weeks) were compared across provinces between immigrant mothers, according to the top 20 maternal birthplaces, and Canadian-born mothers. RESULTS: The proportion of births to immigrant mothers rose overall from 23.7% in 2000 to 30.7% in 2016, but rose unevenly across the provinces. Increases were modest in British Columbia and Ontario; twofold in Alberta, Manitoba and Quebec; and fourfold in Saskatchewan. Compared with PTB rates among Canadian-born mothers, PTB rates were lower among various Asian, African and Western immigrant groups and higher among those from Bangladesh, the Philippines and the Caribbean. Lower birth weights were seen for most source countries, except the United States. These differences were uniform across the provinces, with a few exceptions. DISCUSSION: There were large provincial variations in the proportion of births to immigrant mothers. However, disparities in birth outcomes did not substantially vary across provinces for most immigrant maternal birthplaces, suggesting some degree of generalizability for provincial birth data.

Prenatal care among mothers involved with child protection services in Manitoba: a retrospective cohort study.

BACKGROUND: Prenatal care is one of the most widely used preventive health services; however, use varies substantially. Our objective was to examine prenatal care among women with a history of having a child placed in out-of-home care, and whether their care differed from care among women who did not. METHODS: We used linkable administrative data to create a population-based cohort of women whose first 2 children were born in Manitoba, Canada, between Apr. 1, 1998, and Mar. 1, 2015. We measured the level of prenatal care using the Revised Graduated Prenatal Care Utilization Index, which categorizes care into 5 groups: intensive, adequate, intermediate, inadequate and no care. We compared level of prenatal care for women whose first child was placed in care with level of prenatal care for women who had no contact with care services, using 2 multinomial logistic regression models to calculate odds ratios (ORs). RESULTS: In a cohort of 52 438 mothers, 1284 (2.4%) had their first child placed in out-of-home care before conception of their second child. Mothers whose first child was placed in care had much higher rates of inadequate prenatal care during the pregnancy with their second child than mothers whose first child was not placed in care (33.0% v. 13.4%). The odds of having inadequate rather than adequate prenatal care were more than 4 times higher (OR 4.29, 95% CI 3.68 to 5.01) for women who had their first child placed in care than for women who did not have their first child placed in care. INTERPRETATION: Mothers with a history of having a child taken into care by the child protection services system are at higher risk of having inadequate or no prenatal care in a subsequent pregnancy compared with mothers with no history of involvement with child protection services.

Analysis of the Cariogenic Potential of Various Almond Milk Beverages using a Streptococcus mutans Biofilm Model in vitro.

To evaluate the cariogenic properties of almond milk beverages, 6 almond milks, along with soy and whole bovine milk, were analyzed for their abilities to support Streptococcus mutans biofilm formation and acid production, and their capacity to buffer changes in pH. Biofilm formation by S. mutans was analyzed using an in vitro 96-well plate model and measured by crystal violet staining. Acid production by S. mutans was evaluated by a colorimetric L-lactate assay and pH measurement of bacterial cultures. Buffering capacity was assessed by a pH titration assay. Soy milk supported the most biofilm growth, while the least was observed with unsweetened almond milk (both p < 0.001). Among almond milks, sucrose-sweetened milk led to the highest level of biofilm formation (p < 0.001), while the least was observed with unsweetened milk (p < 0.05). Sucrose-sweetened almond milk yielded the lowest pH (4.56 ± 0.66), followed by soy milk and bovine milk; the highest pH was with unsweetened almond milk (6.48 ± 0.5). When analyzed by pH titration, the unsweetened almond milk displayed the weakest buffering capacity while bovine milk showed the highest (p < 0.001). These results suggest that the almond milk beverages, except those that are sweetened with sucrose, possess limited cariogenic properties, while soy milk exhibits the most cariogenic potential. As milk alternatives become increasingly popular, dentists must counsel their patients that almond milks, especially sucrose-sweetened varieties, have cariogenic potential. For patients who are lactose-intolerant or suffer from milk allergy, almond milks may be a better alternative than soy-based products.

Income inequality, structural racism, and Canada's low performance in health equity.

In 2017, the Commonwealth Fund released a report evaluating 11 countries' healthcare systems on a variety of domains; one of these domains was health equity. Canada's score on health equity placed it among the bottom three countries. This article applies a conceptual framework for health equity developed by the World Health Organization's Commission on the Social Determinants of Health to reflect upon and discuss mechanisms that may help to explain Canada's low score. We discuss the role that two societal-level constructs-income inequality and structural racism-play in shaping population health and health equity. We use publically available data to examine whether income inequality correlates with the Commonwealth Fund report's equity measures. We also comment on the role that Canada's history of colonialism may play in its health equity ranking.

Misidentification and misreporting of antibiotic resistance in Kluyvera bacteremia by blood culture molecular identification panels.

The use of molecular identification panels has advanced the diagnosis for blood stream infections with fast turnaround time and high accuracy. Yet, this technology cannot completely replace conventional blood culture and standardized antibiotic susceptibility testing (AST) given its limitations and occasional false results. Here we present two cases of bacteremia caused by Kluyvera. Its identification and antibiotic resistance were at least partially mispresented by blood culture molecular identification panels on ePlex, Verigene, and Biofire. The detection of CTX-M resistance marker did not align with the susceptibility to the third generation cephalosporins among a wide range of antibiotics for this organism. Conventional extended-spectrum beta-lactamase (ESBL) testing was used to confirm the absence of ESBL. Caution should be taken when managing cases with CTX-M or ESBL detection in blood culture caused by uncommon pathogens. Conventional culture with microbial identification and standardized AST should continue to be the gold standard for routine patient care. IMPORTANCE: This is the first report that highlights the limitations of blood culture molecular identification panels on identifying Kluyvera and its associated antibiotic resistance patterns. Both the false identification and overreporting of antibiotic resistance could mislead the treatment for bacteremia caused by this pathogen. Patient isolation could have been avoided due to the lack of extended-spectrum beta-lactamase (ESBL) activity of the organism. This report emphasizes the importance of confirming rapid identification and antibiotic resistance by molecular technologies with standardized methods. It also provides insight into the development of new diagnostic panels.

Birth Outcomes Among First Nations Birthing Parents Incarcerated While Pregnant: A Linked Administrative Data Study From Manitoba, Canada.

BACKGROUND: In Canada, colonial policies have resulted in health inequities between First Nations and other Canadians. These policies contribute to overrepresentation of First Nations in the criminal legal system, where incarcerated people and their infants face elevated health risks. We investigated the association between prenatal incarceration and adverse birth outcomes among First Nations and other birthing parents in Manitoba, Canada. METHODS: Using linked whole-population administrative data, we identified all live births (2004-2017) in which the birthing parent (First Nations n = 1,449; other Manitoban n = 278) was prenatally incarcerated and compared them to birthing parents who were postnatally incarcerated (First Nations n = 5,290; other Manitoban n = 790) or not incarcerated (First Nations n = 19,950; other Manitoban n = 3,203). We used generalized linear models adjusted for measured confounders with propensity score weighting to calculate risk differences and 95% confidence intervals for adverse birth outcomes among those prenatally versus postnatally incarcerated in each group. RESULTS: Low birthweight births were more likely among First Nations birthing parents who were prenatally (vs. postnatally) incarcerated (risk difference 1.59, 95% CI [.79, 2.38]) but less likely among other Manitoban birthing parents (risk difference -2.33, 95% CI [-4.50, -.16]) who were prenatally (vs. postnatally) incarcerated. Among First Nations, prenatal incarceration was also associated with large-for-gestational-age births, low Apgar scores, and no breastfeeding (vs. postnatal incarceration), as well as preterm births (vs. no incarceration). Among other Manitobans, prenatal incarceration was also associated with small-for-gestational-age births, low Apgar scores, and no breastfeeding (vs. postnatal incarceration), as well as preterm births (vs. no incarceration). CONCLUSIONS: The findings suggest that incarceration may contribute to intergenerational systems of oppression by compromising birth outcomes among First Nations and other birthing parents in Canada and underscore the need to both improve care for pregnant people who are incarcerated and invest in alternatives to incarceration.

Mothers' and Children's Mental Distress and Family Strain during the COVID-19 Pandemic: A Prospective Cohort Study.

BACKGROUND: The COVID-19 pandemic had a widespread impact on families with dependent children. To better understand the impact of the pandemic on families' health and relationships, we examined the association between mothers' and children's mental distress and family strain. METHODS: Three waves of the COVID-19 Impact Survey were analyzed, collected from a subsample of mother-child pairs (n = 157) from the Alberta Pregnancy Outcomes and Nutrition (APrON) longitudinal cohort in Alberta, Canada. Latent class analyses were performed to determine patterns and group memberships in mothers' and children's mental distress and family strain. Multivariable logistic regression models were conducted to test associations between mothers' and children's mental distress and family strain trajectory classes. RESULTS: Mothers with medium/high levels of mental distress were at increased odds of experiencing high family strain compared to those with low levels of distress (medium aOR = 3.90 [95% CI: 1.08-14.03]; high aOR = 4.57 [95% CI: 1.03-20.25]). The association between children's mental distress and family strain was not significant (aOR = 1.75 [95% CI: 0.56-5.20]). CONCLUSION: Mothers' mental distress, but not children's, was associated with family strain during the pandemic. More distressed individuals experienced greater family strain over time, suggesting that this association may become a chronic problem.

Evidence of bias in studies of influenza vaccine effectiveness in elderly patients.

Although studies have shown influenza vaccines to be effective in preventing death in the elderly population, these findings may be the result of selection bias. We examined the relationship between vaccination, age, underlying morbidity, and probability of death in the upcoming year. Vaccination coverage varied in a curvilinear fashion with age, morbidity, and risk of death. Forgoing vaccination predicted death in those who had received vaccinations in the previous 5 years, but it predicted survival in patients who had never before received a vaccination. We conclude that bias is inherent in studies of influenza vaccination and death among elderly patients.

Meaningful variation in performance: what does variation in quality tell us about improving quality?

BACKGROUND: Variance reduction is sometimes considered as a goal of clinical quality improvement. Variance among physicians, hospitals, or health plans has been evaluated as the proportion of total variance (or intraclass correlation, ICC) in a quality measure; low ICCs have been interpreted to indicate low potential for quality improvement at that level. However, the absolute amount of variation, expressed in clinically meaningful units, is less frequently reported. Moreover, changes in variance components have not been studied as quality improves. OBJECTIVES: To examine changes in variance components at primary care physician and medical facility levels as performance improved for 4 quality indicators: systolic blood pressure levels in hypertension; low-density lipoprotein-cholesterol levels in hyperlipidemia; patient-reported care experience scores after primary care visits; and mammography screening rates. POPULATION: Adult members (n = 62,596-410,976) of Kaiser Permanente in Northern California, served by more than 1000 primary care physicians in 35 facilities, from 2001 to 2006. METHODS: Multilevel linear and logistic regression to examine the interphysician and interfacility variances in 4 quality indicators over 6 years, after case-mix adjustment. RESULTS: ICCs were low for all 4 indicators at both levels (0.0021-0.086). Nevertheless, variances at both levels were statistically and clinically significant. For systolic blood pressure and the care experience score, interfacility and interphysician variance as well as ICCs decreased further as quality improved; declines were greater at the facility level. For low-density lipoprotein-cholesterol, variability at both levels increased with quality improvement; and for screening mammography, small declines were not statistically significant for either physicians or facilities. CONCLUSIONS: Low proportions of variance do not predict low potential for quality improvement. Despite low ICCs for facilities, quality improvement efforts directed primarily at facilities improved quality for all 4 indicators.

Overlap between child protection services and the youth justice system: protocol for a retrospective population-based cohort study using linked administrative data in Manitoba, Canada.

INTRODUCTION: Children who have a history of involvement in child protection services (CPS) are over-represented in the youth and adult criminal justice systems. There are significant health and socioeconomic implications for individuals involved in either or both CPS and the justice system. Understanding the 'overlap' between these two systems would provide insight into the health and social needs of this population. This protocol describes a research programme on the relationship between the child welfare and the youth justice systems, looking specifically at the population involved in both CPS and the youth justice system. We will examine the characteristics associated with involvement in these systems, justice system trajectories of individuals with a history of CPS involvement and early adult outcomes of children involved in both systems. METHODS AND ANALYSIS: Administrative data sets will be linked at the individual level for three cohorts born 1991, 1994 and 1998 in Manitoba, Canada. Involvement in CPS will be categorised as 'placed in out-of-home care', 'received in-home services, but was not placed in care' or 'no involvement'. Involvement in the youth justice system will be examined through contacts with police between ages 12 and 17 that either led to charges or did not proceed. Individual, maternal and neighbourhood characteristics will be examined to identify individuals at greatest risk of involvement in one or both systems. ETHICS AND DISSEMINATION: The study was approved by the University of Manitoba Health Research Ethics Board and permission to access data sets has been granted by all data providers. We also received approval for the study from the First Nations Health and Social Secretariat of Manitoba's Health Information Research Governance Committee and the Manitoba Metis Federation. Strategies to disseminate study results will include engagement of stakeholders and policymakers through meetings and workshops, scientific publications and presentations, and social media.

In Utero Antidepressants and Neurodevelopmental Outcomes in Kindergarteners.

OBJECTIVES: To determine if in utero selective serotonin reuptake inhibitor (SSRI) or selective serotonin norepinephrine inhibitor (SNRI) exposure is associated with developmental vulnerability in kindergarten among children whose mothers were diagnosed with prenatal mood or anxiety disorder. METHODS: Linkable administrative data were used to create a population-based cohort of 266 479 mother-child dyads of children born in Manitoba, Canada, between 1996 and 2014, with follow-up through 2015. The sample was restricted to mothers who had a mood or anxiety disorder diagnosis between 90 days before conception (N = 13 818). Exposed women had ≥2 SSRI or SNRI dispensations during pregnancy (n = 2055); unexposed mothers did not have a dispensation of an SSRI or SNRI during pregnancy (n = 10 017). The Early Development Instrument (EDI) was used to assess developmental health in kindergarten children. The EDI is a 104-component kindergarten teacher-administered questionnaire, encompassing 5 developmental domains. RESULTS: Of the 3048 children included in the study who met inclusion criteria and had an EDI, 21.43% of children in the exposed group were assessed as vulnerable on 2 or more domains versus 16.16% of children in the unexposed group (adjusted odds ratio = 1.43; 95% confidence interval 1.08-1.90). Children in the exposed group also had a significant risk of being vulnerable in language and/or cognition (adjusted odds ratio = 1.40; 95% confidence interval 1.03-1.90). CONCLUSIONS: Exposure to SSRIs or SNRIs during pregnancy was associated with an increased risk of developmental vulnerability and an increased risk of deficits in language and/or cognition. Replication of results is necessary before clinical implications can be reached.

Influenza vaccination and mortality: differentiating vaccine effects from bias.

It is widely believed that influenza (flu) vaccination of the elderly reduces all-cause mortality, yet randomized trials for assessing vaccine effectiveness are not feasible and the observational research has been controversial. Efforts to differentiate vaccine effectiveness from selection bias have been problematic. The authors examined mortality before, during, and after 9 flu seasons in relation to time-varying vaccination status in an elderly California population in which 115,823 deaths occurred from 1996 to 2005, including 20,484 deaths during laboratory-defined flu seasons. Vaccine coverage averaged 63%; excess mortality when the flu virus was circulating averaged 7.8%. In analyses that omitted weeks when flu circulated, the odds ratio measuring the vaccination-mortality association increased monotonically from 0.34 early in November to 0.56 in January, 0.67 in April, and 0.76 in August. This reflects the trajectory of selection effects in the absence of flu. In analyses that included weeks with flu and adjustment for selection effects, flu season multiplied the odds ratio by 0.954. The corresponding vaccine effectiveness estimate was 4.6% (95% confidence interval: 0.7, 8.3). To differentiate vaccine effects from selection bias, the authors used logistic regression with a novel case-centered specification that may be useful in other population-based studies when the exposure-outcome association varies markedly over time.

Poverty and Early Childhood Outcomes.

BACKGROUND: Children born into poverty face many challenges. Exposure to poverty comes in different forms, and children may also transition into or out of poverty. In this study, we examine the relationships among various outcomes and different levels of poverty (household and/or neighborhood poverty) at different points during a child's first 5 years. METHODS: We used linkable administrative databases, following 46 589 children born in Manitoba, Canada, between 2000 and 2009 to age 7. Poverty is defined as those receiving welfare and those living in low-income neighborhoods. Four outcomes are measured in the first 5 years (placement in out-of-home care, externalizing mental health diagnosis, asthma diagnosis, and hospitalization for injury), with school readiness assessed between ages 5 and 7. RESULTS: Children born into poverty had greater odds of not being ready for school than children not born into poverty (adjusted odds ratio = 1.54, 1.59, 1.26 for children born in household and neighborhood poverty, household poverty only, and neighborhood poverty only, respectively; all significant at P < .05). Similar patterns were seen across outcomes. For those born into neighborhood poverty, the odds of school readiness were higher only if children moved before age 2. CONCLUSIONS: The level of poverty (household or neighborhood) and its duration modify the relationship between early poverty and childhood outcomes. Covariate adjustment generally weakens but does not eliminate these relationships.

The multigenerational effects of adolescent motherhood on school readiness: A population-based retrospective cohort study.

BACKGROUND: Children born to adolescent mothers generally perform more poorly on school readiness assessments than their peers born to adult mothers. It is unknown, however, whether this relationship extends to the grandchildren of these adolescent mothers. This paper examines the multi-generational outcomes associated with adolescent motherhood by testing whether the grandchildren of adolescent mothers also have lower school readiness scores than their peers; we further assessed if this relationship was moderated by whether the child's mother was an adolescent mother. METHODS: We used population-based data to conduct the retrospective cohort study of children born in Manitoba, Canada, 2000-2009, whose mothers were born 1979-1997 (n = 11,326). Overall school readiness and readiness on five domains of development were analyzed using logistic regression models. RESULTS: Compared with children whose mothers and grandmothers were both ≥ 20 at the birth of their first child, those born to grandmothers who were < 20 and mothers who were ≥ 20 years old at the birth of their first child had 39% greater odds of being not ready for school (95% CI: 1.22-1.60). Children whose grandmothers were ≥ 20 and mothers were < 20 at the birth of their first child had 25% greater odds of being not ready for school (95% CI: 1.11-1.41), and children born to grandmothers and mothers who were both <20 at the birth of their first child had 35% greater odds of being not ready for school (95% CI: 1.18-1.54). CONCLUSIONS: These findings suggest a multigenerational effect of adolescent motherhood on school readiness.

Sex differences in event-related potential (ERP) waveforms of primary psychotic disorders: A systematic review.

Research aimed at understanding primary psychotic disorders such as schizophrenia, schizophreniform disorder, and schizoaffective disorder, with electrophysiological methods has flourished over recent years. However, a significant component that is often overlooked or underreported in electrophysiological research of psychosis is the factor of biological sex. Thus, the goal of this systematic review was to summarize the current understanding of EEG sex differences in primary psychotic disorders. Our study found a consistent sex difference relating to the P300 component (male amplitude < females), and that research examining sex differences of ERP waveforms, other than the P300, is very limited with ambiguous findings. This review also addressed the lack of consideration of sex as an influencing factor in electrophysiological research.

Pharmacist dispensed naloxone: Knowledge, availability, participation and cost in selected California counties.

BACKGROUND: In 2014, California signed into law AB1535 permitting pharmacists to dispense naloxone upon request and without physician or midlevel provider prescription. OBJECTIVE: We sought to determine pharmacist knowledge of AB1535, participation, availability of naloxone, future plans for participation, and out-of-pocket charges to consumers amongst outpatient pharmacies in selected California counties. METHODS: All pharmacies in Plumas, Lake, Lassen, Humboldt, Shasta, Fresno, and San Diego Counties were identified. Between January 30 and March 30, 2017, pharmacies meeting inclusion criteria were contacted and the pharmacist-on-duty were queried regarding knowledge, participation, availability, and cost of naloxone. RESULTS: A total of 2296 pharmacies were identified in the 7 counties. Twenty-six were unwilling or unable to participate and an additional 1648 were excluded because of licensing or special pharmacy status. Six-hundred-twenty-two pharmacies completed the survey. There was variation in knowledge of AB1535, participation in, immediate availability of naloxone, charge, and expressed future interest in participation identified. Charge to consumers was similarly variable amongst surveyed pharmacies within counties. CONCLUSIONS: Despite considerable public health and political support, the passage of CA AB1535 has not resulted in broad current, future planned participation, or availability of naloxone in selected counties. Out-of-pocket costs to the consumer remain highly variable.

Placement in Care in Early Childhood and School Readiness: A Retrospective Cohort Study.

The current study examined school readiness for children placed in care of child protection services before age 5. This association was assessed using a population-based cohort of children born in Manitoba, Canada, between 2000 and 2009 ( n = 53,477) and subcohorts of discordant siblings (one sibling taken into care, one sibling not taken into care; n = 809) and discordant cousins ( n = 517). In the population analysis, children placed in care were significantly less likely to be ready for school; this difference was not seen in the discordant sibling or cousin analysis. The findings suggested that differences in school readiness for children placed in care are a result of broader social factors affecting families, not placement into care.

Association between participation in the Families First Home Visiting programme and First Nations families' public health outcomes in Manitoba, Canada: a retrospective cohort study using linked administrative data.

OBJECTIVE: To determine whether the Families First Home Visiting (FFHV) programme, which provides home visiting services to families across Manitoba, is associated with improved public health outcomes among First Nations families facing multiple parenting challenges. DESIGN: Retrospective cohort study using population-based administrative data. SETTING: Manitoba, Canada. PARTICIPANTS: First Nations children born in Manitoba in 2003-2009 (n=4010) and their parents enrolled in FFHV compared with non-enrolled families with a similar risk profile. INTERVENTION: FFHV supports public health in Manitoba by providing home visiting services to First Nations and non-First Nations families with preschool children and connecting them with resources in their communities. OUTCOMES: Predicted probability (PP) and relative risk (RR) of childhood vaccination, parental involvement in community support programmes and children's development at school entry. RESULTS: FFHV participation was associated with higher rates of complete childhood vaccination at age 1 (PP: FFHV 0.715, no FFHV 0.661, RR 1.08, 95% CI 1.03 to 1.14) and age 2 (PP: FFHV 0.465, no FFHV 0.401, RR 1.16, 95% CI 1.08 to 1.25), and with parental involvement in community support groups (PP: FFHV 0.149, no FFHV 0.097, RR 1.54, 95% CI 1.27 to 1.86). However, there was no difference between FFHV participants and non-participants in rates of children being vulnerable in at least one developmental domain at age 5 (PP: FFHV 0.551, no FFHV 0.557, RR 1.00, 95% CI 0.91 to 1.11). CONCLUSIONS: FFHV supports First Nations families in Manitoba by promoting childhood vaccination and connecting families to parenting resources in their communities, thus playing an important role in fulfilling the mandate of public health practice.

Evaluating the Manitoba Infant Feeding Database: a Canadian infant feeding surveillance system.

OBJECTIVE: The Manitoba Infant Feeding Database (MIFD) is being piloted as a surveillance system leveraging infant vaccination visits as a point of contact to collect infant feeding data during the first year of life. The objective of this study was to assess data quality and acceptability of the MIFD as a sustainable population-based surveillance system. METHODS: Internal completeness and internal validity were measured to assess data quality. Internal completeness was defined as the number of completed data fields out of the total number of data fields. Internal validity was defined as the proportion of translation errors from one level of the system, the paper questionnaire, to the next, the electronic database. A survey assessed staff's acceptance of data collection and submission processes. RESULTS: A total of 947 records were reviewed. Data were 98.5% complete. Discrepancies were noted in 13.5% of data. The survey response rate was 78.4%. Nearly all respondents reported that the MIFD data collection tool was easy to use (96.6% agreed or strongly agreed). Whereas some challenges were identified, the majority were willing to continue with the MIFD data collection tool and process (93.1%). CONCLUSION: Results from this evaluation suggest that the MIFD data collection process worked well; however, data validation will require human resources. The MIFD approach provides a sustainable mechanism for collecting data on infant feeding for surveillance and research purposes.

The prevalence, burden, and treatment of urinary incontinence among women in a managed care plan.

OBJECTIVE: Urinary incontinence (UI) symptoms are common among women, yet only a small proportion of women with incontinence receive a diagnosis and treatment. We used survey and utilization data to determine the prevalence, burden, and treatment use for incontinence among women at Kaiser Permanente in Northern California. METHODS: In 2002, we surveyed 6726 female health plan members about health issues, including incontinence. We assessed type and bothersomeness of incontinence symptoms in the previous 7 days. For survey respondents and a 10% sample of female plan members (n = 108,825), we assessed use from 1997 to 2003. RESULTS: The survey response rate was 49.7% (3344 of 6726); 44% of respondents reported incontinence symptoms in the previous 7 days, with over half of these women reporting that these symptoms bothered them. Fifteen percent of women with incontinence symptoms had a diagnosis consistent with incontinence in the previous 5 years. One third of the women reporting current bothersome incontinence and 14 or more incontinence episodes in the last 7 days had a diagnosis consistent with incontinence in the previous 5 years. Among women who had received medical or surgical treatment for incontinence in the previous 5 years, approximately half currently report being bothered by their symptoms. CONCLUSIONS: Prevalence of bothersome incontinence symptoms among females in a prepaid health plan is high. However, only a small proportion of these women received a diagnosis or treatment for incontinence symptoms in the last 5 years. Efforts to improve the detection and treatment of bothersome incontinence symptoms are needed.