Inequalities in access to prenatal care during the COVID-19 pandemic: Analysis of a population-based cohort.

BACKGROUND: Before the COVID-19 pandemic, access to prenatal care was lower among some socio-demographic groups. This pandemic caused disruptions to routine preventative care, which could have increased inequalities. OBJECTIVES: To investigate if the COVID-19 pandemic increased inequalities in access to prenatal care among those who are younger, live in rural areas, have a lower socio-economic situation (SES) and are recent immigrants. METHODS: We used linked administrative datasets from ICES to identify a population-based cohort of 455,245 deliveries in Ontario from January 2018 to December 2021. Our outcomes were first-trimester prenatal visits, first-trimester ultrasound and adequacy of prenatal care. We used joinpoint analysis to examine outcome time trends and identify trend change points. We stratified analyses by age, rural residence, SES and recent immigration, and examined risk differences (RD) with 95% confidence intervals (CI) between groups at the beginning and end of the study period. RESULTS: For all outcomes, we noted disruptions to care beginning in March or April 2020 and returning to previous trends by November 2020. Inequalities were stable across groups, except recent immigrants. In July 2017, 65.0% and 69.8% of recent immigrants and non-immigrants, respectively, received ultrasounds in the first trimester (RD -4.8%, 95% CI -8.0, -1.5). By October 2020, this had increased to 75.4%, with no difference with non-immigrants (RD 0.4%, 95% CI -2.4, 3.2). Adequacy of prenatal care showed more intensive care as of November 2020, reflecting a higher number of visits. CONCLUSIONS: We found no evidence that inequalities between socio-economic groups that existed prior to the pandemic worsened after March 2020. The pandemic may be associated with increased access to care for recent immigrants. The introduction of virtual visits may have resulted in a higher number of prenatal care visits.

Developing non-response weights to account for attrition-related bias in a longitudinal pregnancy cohort.

BACKGROUND: Prospective cohorts may be vulnerable to bias due to attrition. Inverse probability weights have been proposed as a method to help mitigate this bias. The current study used the "All Our Families" longitudinal pregnancy cohort of 3351 maternal-infant pairs and aimed to develop inverse probability weights using logistic regression models to predict study continuation versus drop-out from baseline to the three-year data collection wave. METHODS: Two methods of variable selection took place. One method was a knowledge-based a priori variable selection approach, while the second used Least Absolute Shrinkage and Selection Operator (LASSO). The ability of each model to predict continuing participation through discrimination and calibration for both approaches were evaluated by examining area under the receiver operating curve (AUROC) and calibration plots, respectively. Stabilized inverse probability weights were generated using predicted probabilities. Weight performance was assessed using standardized differences of baseline characteristics for those who continue in study and those that do not, with and without weights (unadjusted estimates). RESULTS: The a priori and LASSO variable selection method prediction models had good and fair discrimination with AUROC of 0.69 (95% Confidence Interval [CI]: 0.67-0.71) and 0.73 (95% CI: 0.71-0.75), respectively. Calibration plots and non-significant Hosmer-Lemeshow Goodness of Fit Tests indicated that both the a priori (p = 0.329) and LASSO model (p = 0.242) were well-calibrated. Unweighted results indicated large (> 10%) standardized differences in 15 demographic variables (range: 11 - 29%), when comparing those who continued in the study with those that did not. Weights derived from the a priori and LASSO models reduced standardized differences relative to unadjusted estimates, with the largest differences of 13% and 5%, respectively. Additionally, when applying the same LASSO variable selection method to develop weights in future data collection waves, standardized differences remained below 10% for each demographic variable. CONCLUSION: The LASSO variable selection approach produced robust weights that addressed non-response bias more than the knowledge-driven approach. These weights can be applied to analyses across multiple longitudinal waves of data collection to reduce bias.

Women's Mental Health up to Eight Years after Childbirth and Associated Risk Factors: Longitudinal Findings from the All Our Families Cohort in Canada.

OBJECTIVE: This study examined the prevalence of elevated maternal anxiety and/or depression symptoms up to eight years after childbirth and the association between role and relationship strains during parenting and mental health challenges from three to eight years after childbirth. METHODS: This study used data from the All Our Families longitudinal pregnancy cohort. Role and relationship strain factors and anxiety and depression symptoms were measured at repeated time points from four months to eight years after childbirth. The proportion of women with elevated anxiety and/or depression was calculated at each available time point. Generalized estimating equation models were used to examine the association between role and relationship strain factors and anxiety and/or depression from three to eight years after childbirth. Predicted probability of having anxiety and/or depression was estimated across those with and without challenges with roles and relationships. The models were adjusted for known risk factors such as maternal income and perinatal anxiety and/or depression. RESULTS: The prevalence of elevated anxiety and/or depression ranged from 18.8% (at four months) to 26.2% (at eight years). The adjusted odds ratio of anxiety and/or depression was 3.5 (95% CI = 2.9, 4.3) for those juggling family responsibilities and 2.4 (95% CI = 2.0, 3.0) for those with stressful partner relationship compared to their counterparts. Similarly, experiencing financial crunch and poor partner relationship were associated with increased mental health difficulties. Women without challenges in roles or relationships had a 23% lower predicted probability of anxiety and/or depression than those with the challenges. CONCLUSIONS: Monitoring mothers for anxiety and depression beyond the postpartum period and strategies that address role and relationship challenges may be valuable to women at risk of anxiety and depression.

Changes and predictors of maternal depressive and anxiety symptoms during the COVID-19 pandemic.

Longitudinal changes in maternal depressive and anxiety symptoms and predictors of symptom variation among a group of middle-to-upper income Canadian women (n = 2152) were examined prior to the pandemic (2017-2019) and at three pandemic timepoints (May-July 2020, March-April 2021, November-December 2021). Mean maternal depression and anxiety scores were elevated throughout the pandemic. Pre-pandemic depressive symptoms were associated with greater increases in depressive symptoms. Coping and relationship quality were protective factors. Supporting the development of coping strategies may mitigate mental health concerns among mothers.

Cesarean Deliveries Among Immigrant and Canadian-Born Women in a Representative Community Population in Canada: A Retrospective Cohort Study.

OBJECTIVE: To examine differences in the rate of cesarean delivery between Canadian-born women and immigrants to Canada and by duration of time in Canada and rate of cesarean delivery in their country-of-origin. METHODS: We used linked data from hospitalization records and the Canadian Community Health Survey for all deliveries after 20 weeks gestation between 2002 and 2017 in Canada (excluding Québec). Odds of cesarean delivery in recent immigrants (<5 y in Canada) and non-recent immigrants (≥5 y in Canada) were compared with those of Canadian-born women using multivariable logistic regression. Immigrants were further categorized using the cesarean delivery rate in their country-of-origin as low (<10%), medium (≥10 to <35%), or high (≥35%). RESULTS: Of the 53 505 women included, 89% were Canadian-born, 4% were recent immigrants and 7% were non-recent immigrants. Overall, 28.6% of women had a cesarean delivery. After adjusting for medical and socio-economic factors, the odds of cesarean delivery among recent immigrants (OR 1.12; 95% CI 0.95-1.34) and non-recent immigrants (OR 1.11; 95% CI 0.98-1.25) did not differ statistically from those of Canadian-born women. Recent immigrants from countries with lower cesarean delivery rates had higher odds of cesarean delivery (OR 1.34; 95% CI 1.05-1.70), whereas the odds of cesarean for recent immigrants from medium- and high-rate countries did not differ from those of Canadian-born women. CONCLUSION: After accounting for demographic and medical factors, few differences remained in cesarean delivery rates between immigrants and Canadian-born women. Country-of-origin practices are unlikely to reflect preferences for cesarean delivery in immigrant women in Canada.

Impact of the ICD-9-CM to ICD-10-CM transition on the incidence of severe maternal morbidity among delivery hospitalizations in the United States.

BACKGROUND: Surveillance of maternal mortality and severe maternal morbidity is important to identify temporal trends, evaluate the impact of clinical practice changes or interventions, and monitor quality of care. A common source for severe maternal morbidity surveillance is hospital discharge data. On October 1, 2015, all hospitals in the United States transitioned from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding for diagnoses and procedures. OBJECTIVE: This study aimed to evaluate the impact of the transition from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding systems on the incidence of severe maternal morbidity in the United States in hospital discharge data. STUDY DESIGN: Using data from the National Inpatient Sample, obstetrical deliveries between January 1, 2012, and December 31, 2017, were identified using a validated case definition. Severe maternal morbidity was defined using the International Classification of Diseases, Ninth Revision, Clinical Modification (January 1, 2012, to September 30, 2015) and the International Classification of Diseases, Tenth Revision, Clinical Modification (October 1, 2015, to December 31, 2017) codes provided by the Centers for Disease Control and Prevention. An interrupted time series and segmented regression analysis was used to assess the impact of the transition from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding on the incidence of severe maternal morbidity per 1000 obstetrical deliveries. RESULTS: From 22,751,941 deliveries, the incidence of severe maternal morbidity in the International Classification of Diseases, Ninth Revision, Clinical Modification coding era was 19.04 per 1000 obstetrical deliveries and decreased to 17.39 per 1000 obstetrical deliveries in the International Classification of Diseases, Tenth Revision, Clinical Modification coding era (P<.001). The transition to International Classification of Diseases, Tenth Revision, Clinical Modification coding led to an immediate decrease in the incidence of severe maternal morbidity (-2.26 cases of 1000 obstetrical deliveries) (P<.001). When blood products transfusion was removed from the case definition, the magnitude of the decrease in the incidence of SMM was much smaller (-0.60 cases/1000 obstetric deliveries), but still significant (P<.001). CONCLUSION: After the transition to the International Classification of Diseases, Tenth Revision, Clinical Modification coding for health diagnoses and procedures in the United States, there was an abrupt statistically significant and clinically meaningful decrease in the incidence of severe maternal morbidity in hospital discharge data. Changes in the underlying health of the obstetrical population are unlikely to explain the sudden change in severe maternal morbidity. Although much work has been done to validate the International Classification of Diseases, Ninth Revision, Clinical Modification codes for severe maternal morbidity, it is critical that validation studies be undertaken to validate the International Classification of Diseases, Tenth Revision, Clinical Modification codes for severe maternal morbidity to permit ongoing surveillance, quality improvement, and research activities that rely on hospital discharge data.

Trajectories of social support in pregnancy and early postpartum: findings from the All Our Families cohort.

PURPOSE: Low social support during the perinatal period can increase the risk of postpartum depression and anxiety after giving birth but little is known about women's trajectories of social support during this time. This study will identify trajectories of social support among women from second trimester to 4-month postpartum, and the characteristics associated with different trajectories. METHODS: Data from the All Our Families longitudinal birth cohort was used to assess women's perceived social support during their second trimester, third trimester, and at 4-month postpartum (n = 3387). Group-based trajectory modeling was used to determine the number of groups, shape of trajectories, and proportion of women with differing trajectories. Multinomial regression was used to compare probability of group membership. RESULTS: Six distinct trajectory groups were identified, with the majority of participants belonging to groups with stable, high social support (60.6%). Only 2.7% of women had consistently low levels of social support, and 2.3% had rising levels. Membership in groups with lower levels of social support was associated with lower incomes and minority ethnicity. Women whose support improved over time may be more likely to be employed in pregnancy than those whose support remained low. CONCLUSION: Trajectories of social support are relatively stable in pregnancy and early postpartum. Socio-demographic indicators of vulnerability predict initial levels of support, and participating in the workforce may help improve perception of support over time.

Mitigation of Participant Loss to Follow-Up Using Facebook: All Our Families Longitudinal Pregnancy Cohort.

BACKGROUND: Facebook, a popular social media site, allows users to communicate and exchange information. Social media sites can also be used as databases to search for individuals, including cohort participants. Retaining and tracking cohort participants are essential for the validity and generalizability of data in longitudinal research. Despite numerous strategies to minimize loss to follow-up, maintaining contact with participants is time-consuming and resource-intensive. Social media may provide alternative methods of contacting participants who consented to follow-up but could not be reached, and thus are potentially "lost to follow-up." OBJECTIVE: The aim of this study was to determine if Facebook was a feasible method for identifying and contacting participants of a longitudinal pregnancy cohort who were lost to follow-up and re-engaging them without selection bias. METHODS: This study used data from the All Our Families cohort. Of the 2827 mother-child dyads within the cohort, 237 participants were lost to follow-up. Participants were considered lost to follow-up if they had agreed to participate in additional research, completed at least one of the perinatal questionnaires, did not complete the 5-year postpartum questionnaire, and could not be contacted after numerous attempts via phone, email, or mail. Participants were considered to be matched to a Facebook profile if 2 or more characteristics matched information previously collected. Participants were sent both a friend request and a personal message through the study's Facebook page and were invited to verify their enrollment in the study. The authors deemed a friend request was necessary because of the reduced functionality of nonfriend direct messaging at the time. If the participant accepted the study's friend request, then a personalized message was sent. Participants were considered reconnected if they accepted the friend request or responded to any messages. Participants were considered re-engaged if they provided up-to-date contact information. RESULTS: Compared with the overall cohort, participants who were lost to follow-up (n=237) were younger (P=.003), nonmarried (P=.02), had lower household income (P<.001), less education (P<.001), and self-identified as being part of an ethnic minority (P=.02). Of the 237 participants considered lost to follow-up, 47.7% (113/237) participants were identified using Facebook. Among the 113 identified participants, 77.0% (87/113) were contacted, 32.7% (37/113) were reconnected, and 17.7% (20/113) were re-engaged. No significant differences were found between those identified on Facebook (n=113) and those who were not able to be identified (n=124). CONCLUSIONS: Facebook identified 47.6% (113/237) of participants who were considered lost to follow-up, and the social media site may be a practical tool for reconnecting with participants. The results from this study demonstrate that social networking sites, such as Facebook, could be included in the development of retention practices and can be implemented at any point in cohort follow-up.

Caring for pregnant refugee women in a turbulent policy landscape: perspectives of health care professionals in Calgary, Alberta.

BACKGROUND: Female refugees can be a vulnerable population, often having suffered through traumatic events that pose risks to their health, especially during pregnancy. Pregnancy can be an entry point into the health care system, providing health care professionals the opportunity to gain women's trust, connect refugees with resources, and optimize the health of mother and child. Policies surrounding the provision and funding of health care services to refugees can impact access to and quality of care. The aim of our study was to understand the experiences of health care professionals caring for pregnant refugee women in Calgary, AB, taking into consideration recent contextual changes to the refugee landscape in Canada. METHODS: We conducted ten semi-structured interviews with health care professionals who provided regular care for pregnant refugee women at a refugee health clinic and major hospital in Calgary, Alberta. Interviews were recorded, transcribed, and analyzed using an interpretive description methodology. RESULTS: Health care providers described several barriers when caring for pregnant refugees, including language barriers, difficulty navigating the health care system, and cultural barriers such as managing traditional gender dynamics, only wanting a female provider and differences in medical practices. Providers managed these barriers through strategies including using a team-based approach to care, coordinating the patient's care with other services, and addressing both the medical and social needs of the patient. The federal funding cuts added additional challenges, as many refugees were left without adequate health coverage and the system was complicated to understand. Health care providers developed creative strategies to maximize coverage for their patients including paying out of pocket or relying on donations to care for uninsured refugees. Finally, the recent Syrian refugee influx has increased the demand on service providers and further strained already limited resources. CONCLUSION: Health care providers caring for pregnant refugee women faced complex cultural and system-level barriers, and used multiple strategies to address these barriers. Additional system strains add extra pressure on health care professionals, requiring them to quickly adjust and accommodate for new demands.

Maternal adverse childhood experiences and antepartum risks: the moderating role of social support.

The aims of the current study were to examine the association between maternal adverse childhood experiences (ACEs) and antepartum health risks, and to investigate whether social support moderated this association. It was hypothesized that ACEs would be associated with antepartum health risks; however, social support in the prenatal period would buffer mothers from the deleterious consequences of ACEs. Data from 1994 women (mean age = 31 years) and their infants were collected from a longitudinal cohort recruited in health care offices in Alberta, Canada. Pregnant women completed questionnaires related to ACEs prior to the age of 18 and prenatal social support, and a health care professional assessed the mother's antepartum health risk. ACEs included physical, emotional, and sexual abuse, exposure to domestic violence, as well as exposure to household dysfunction such as parental substance use, mental illness, or incarceration. Regression analyses demonstrated a positive association between ACEs and antepartum health risks. However, a significant interaction between maternal ACEs and social support was also observed. Specifically, women exposed to high ACEs and low social support in pregnancy had high antepartum health risks. However, among mothers who had high ACEs but also high levels of social support, there was no association between ACEs and antepartum health risk. A history of ACEs can place mothers at risk of antepartum health complications. However, a resiliency effect was observed: women with a history of ACEs were buffered from experiencing antepartum health risks if they reported high levels of social support in pregnancy.

Vulnerable Women's Perceptions of Individual Versus Group Prenatal Care: Results of a Cross-Sectional Survey.

Introduction Vulnerable pregnant women (e.g. women with low socio-economic status or recent immigrants) are less likely to receive adequate prenatal care or to attend perinatal education classes. CenteringPregnancy (CP) is a model of group prenatal care which combines assessment, education and support. This study aimed to assess patient experience among vulnerable women in group prenatal care compared to individual care. Methods Women participating in CP at a community-based health centre in urban Alberta were eligible to participate. A convenience sample of women who received individual care at a low-risk maternity clinic served as comparison. Women were asked a series of questions on their prenatal care experience. Demographic and patient responses were compared using Chi square, fisher's exact and t tests. Results Forty-five women accessing CP and 92 women accessing individual care participated. Women in CP were younger, more likely to be single and having their first baby than women in individual care. Women in CP were significantly more likely to report having received enough information on exercise during pregnancy (92 vs. 66%, p = 0.002), breastfeeding (95 vs. 70%, p = 0.002) and baby care (95 vs. 67%, p = 0.001). Women in CP were more likely to report that they felt their prenatal care providers were interested in how the pregnancy was affecting their life (100 vs. 93%, p ≤ 0.001). Discussion Group prenatal care provides a positive experience and improved information exchange among vulnerable populations. Programs interested in engaging, educating and empowering vulnerable pregnant women may benefit from implementation of group care.

Risk factors for antenatal anxiety: A systematic review of the literature.

BACKGROUND: Given the prevalence of antenatal anxiety and its consistent associations with adverse pregnancy and child outcomes, early detection and management of anxiety are essential. OBJECTIVE: The aim was to identify risk factors for anxiety among pregnant women by systematically reviewing original research. METHODS: Cross-sectional, case-control and cohort studies that examined associations between antenatal anxiety and at least one potential risk factor prospectively or retrospectively and measured anxiety independent from other mental health conditions were included. Studies rated strong/moderate in methodological quality appraisal were used to synthesise the evidence. RESULTS: Factors associated with greater risk of anxiety included previous pregnancy loss, medical complications, childhood abuse, intimate partner violence, denial/acceptance coping styles, personality traits, inadequate social support, history of mental health problems, high perceived stress and adverse life events. CONCLUSIONS: Several risk factors identified in this review are detectable in routine prenatal care visits (e.g. previous pregnancy loss, pregnancy complications), potentially modifiable (e.g. coping styles, social support, partner factors) and can be identified prior to pregnancy (e.g. psychosocial factors), underlining the significance of pre-conception mental health screening.

Participatory science and innovation for improved sanitation and hygiene: process and outcome evaluation of project SHINE, a school-based intervention in Rural Tanzania.

BACKGROUND: Diarrheal disease is a major cause of mortality and morbidity in low and middle income countries with children being disproportionately affected. Project SHINE (Sanitation & Hygiene INnovation in Education) is a grassroots participatory science education and social entrepreneurship model to engage youth and the wider community in the development of sustainable strategies to improve sanitation and hygiene. METHODS: Based in rural and remote Tanzania, this pilot study engaged pastoralist high-school students and communities in the development and evaluation of culturally and contextually relevant strategies to improve sanitation and hygiene. Using a train-the-trainer approach, key activities included teacher workshops, school-based lessons, extra-curricular activities, community events and a One Health sanitation science fair which showcased projects related to water, sanitation and hygiene in relation to human and animal health. The process and outcome of the study were evaluated through qualitative interviews and focus group discussions with diverse project participants, as well as pre- and post- questionnaires completed by students on knowledge, attitudes and practices concerning sanitation and hygiene. RESULTS: The questionnaire results at baseline and follow-up showed statistically significant improvements on key measures including a decrease in unhygienic behaviors, an increase in the perceived importance of handwashing and intention to use the toilet, and increased communication in the social network about the importance of clean water and improved sanitation and hygiene practices, however there were no significant changes in sanitation related knowledge. Qualitative data highlighted strong leadership emerging from youth and enthusiasm from teachers and students concerning the overall approach in the project, including the use of participatory methods. There was a high degree of community engagement with hundreds of community members participating in school-based events. Sanitation science fair projects addressed a range of pastoralist questions and concerns regarding the relationship between water, sanitation and hygiene. Several projects, such as making soap from local materials, demonstrate potential as a sustainable strategy to improve health and livelihoods in the long-term. CONCLUSIONS: The Project SHINE model shows promise as an innovative capacity building approach and as an engagement and empowerment strategy for youth and communities to develop locally sustainable strategies to improve sanitation and hygiene.

The Impact of Introducing Centering Pregnancy in a Community Health Setting: A Qualitative Study of Experiences and Perspectives of Health Center Clinical and Support Staff.

Objectives Introducing new programming into an existing setting may be challenging. Understanding how staff and clinicians who are not directly involved in program delivery view the program can help support program implementation. This study aimed to understand how peripheral staff and clinicians perceived a newly implemented Centering Pregnancy group prenatal care program in a community-based health center and its impact on clinic operations. Methods Semi-structured interviews were conducted with a purposive sample of 12 staff members at a community-based health center. The interview guide covered topics such as perceptions of Centering Pregnancy and how the program impacted their work. An interpretive description approach was used to analyze the interview data. A coding framework was developed iteratively and all interview data were analyzed independently by multiple researchers. Results Staff had overall positive perceptions of Centering Pregnancy, but the level of understanding about the program varied widely. Most respondents viewed the Centering Pregnancy program as separate from other programs offered by the clinic, which created both opportunities and challenges. Opportunities included increased cross-referrals between established services and Centering Pregnancy. Challenges included a lack of communication about responsibilities of staff in relation to Centering Pregnancy patients. Impact on staff and overall clinic operations was perceived to be minimal to moderate, and most tensions related to roles and expectations were resolved. Conclusions for Practice Clear communication regarding fit within clinic structures and processes and expectations of staff in relation to the program was critical to the integration of Centering Pregnancy program into an established health center.

Preterm Birth and Social Support during Pregnancy: a Systematic Review and Meta-Analysis.

BACKGROUND: Additional social support is often recommended for women during the prenatal period to optimise birth outcomes, specifically to avoid preterm birth. Social support is thought to act in one of two ways: by reducing stress and anxiety, or by providing coping mechanisms for women with high stress. However, evidence in this area is mixed. The purpose of this meta-analysis is to determine if low levels of social support are associated with an increased risk for preterm birth. METHODS: Six databases were searched for randomised control trials and cohort studies regarding social support and preterm birth with no limits set on date or language. Inclusion criteria included the use of a validated instrument to measure social support, and studies conducted in high-income or high-middle-income countries. RESULTS: There were 3467 records retrieved, 16 of which met the inclusion criteria. Eight studies (n = 14 630 subjects) demonstrated a pooled odds ratio (OR) of 1.22 (95% CI 0.84, 1.76) for preterm birth in women with low social support compared with high social support. Among women with high stress levels, two studies (n = 6374 subjects) yielded a pooled OR of 1.52 (95% CI 1.18, 1.97). The results of six studies could not be pooled due to incompatibility of outcome measures. CONCLUSIONS: There is no evidence for a direct association between social support and preterm birth. Social support, however, may provide a buffering mechanism between stress and preterm birth.

Impact of Asthma Medications During Pregnancy on Asthma Exacerbation, Maternal, and Neonatal Outcomes.

BACKGROUND: Asthma affects 5% to 13% of pregnant women, and many require daily pharmacotherapy to achieve asthma control; however, adherence to medication during pregnancy often decreases. OBJECTIVE: To understand the association between the use of or adherence to asthma medication with asthma exacerbation and maternal/neonatal outcomes. METHODS: Using linked population-based administrative databases from Alberta, Canada (2012-2018), pregnant women with asthma were categorized based on asthma medication use 1 year before pregnancy: short-acting ß-agonists (SABA), inhaled corticosteroids (ICS), and ICS with long-acting ß-agonists (ICS+LABA). Women on ICS+LABA were grouped by trajectory of adherence during pregnancy using group-based trajectory modeling. Logistic regressions were used to estimate the associations between the use of or trajectories of adherence to asthma medication during pregnancy with asthma exacerbation and maternal/neonatal outcomes. RESULTS: Overall, 13,509 of 238,751 (5.7%) pregnant women had asthma before pregnancy (SABA: 24.7%; ICS: 12.5%; ICS+LABA: 25.1%; none: 36.1%). The use of SABA (adjusted odds ratio [aOR]: 1.79, 95% confidence interval [CI]: 1.21, 2.64), ICS (aOR: 3.37, 95% CI: 2.10, 5.39), and ICS+LABA (aOR: 3.64, 95% CI: 2.57, 5.17) had greater odds of disease exacerbation than no asthma medication during pregnancy. ICS+LABA adherence groups during pregnancy included low (79.8%), moderate-to-decreasing (14.0%), and moderate-to-increasing (6.2%). The moderate-to-decreasing (aOR: 1.45, 95% CI: 1.14, 1.84) and moderate-to-increasing (aOR: 2.06, 95% CI: 1.50, 2.83) adherence groups had greater odds of disease exacerbation than the low adherence group. ICS use during pregnancy decreased odds of preterm birth (aOR: 0.62; 95% CI: 0.39, 0.99) and neonatal intensive care unit admission (aOR: 0.66; 95% CI: 0.45, 0.97). Other group comparisons were not statistically significant. CONCLUSIONS: Our study shows the importance of continuing asthma maintenance medication during pregnancy to improve outcomes. Future research should study the postpartum and long-term outcomes with asthma medication during pregnancy.

Impact evaluation of the TAMANI project to improve maternal and child health in Tanzania.

BACKGROUND: The Tabora Maternal and Newborn Health Initiative project was a multicomponent intervention to improve maternal and newborn health in the Tabora region of Tanzania. Components included training healthcare providers and community health workers, infrastructure upgrades, and improvements to health management. This study aimed to examine the impact of trainings on four key outcomes: skilled birth attendance, antenatal care, respectful maternity care and patient-provider communication. METHODS: Trainings were delivered sequentially at four time points between 2018 and 2019 in eight districts (two districts at a time). Cross-sectional surveys were administered to a random sample of households in all districts at baseline and after each training wave. Due to practical necessities, the original stepped wedge cluster randomised design of the evaluation was altered mid-programme. Therefore, a difference-in-differences for multiple groups in multiple periods was adopted to compare outcomes in treated districts to not yet treated districts. Risk differences were estimated for the overall average treatment effect on the treated and group/time dynamic effects. RESULTS: Respondents reported 3895 deliveries over the course of the study. The intervention was associated with a 12.9 percentage point increase in skilled birth attendance (95% CI 0.4 to 25.4), which began to increase 4 months after the end of training in each district. There was little evidence of impact on antenatal care visits, respectful treatment during delivery and patient-provider communication. CONCLUSION: Interventions to train local healthcare workers in basic and comprehensive emergency obstetric and newborn care increased skilled birth attendance but had limited impact on other pregnancy-related outcomes.

How do perceptions of Covid-19 risk impact pregnancy-related health decisions? A convergent parallel mixed-methods study protocol.

INTRODUCTION: Pregnant people have a higher risk of severe COVID-19 disease. They have been disproportionately impacted by COVID-19 infection control policies, which exacerbated conditions resulting in intimate partner violence, healthcare access, and mental health distress. This project examines the impact of accumulated individual health decisions and describes how perinatal care and health outcomes changed during the COVID-19 pandemic. OBJECTIVES: Quantitative strand: Describe differences between 2019, 2021, and 2022 birth groups related to maternal vaccination, perinatal care, and mental health care. Examine the differential impacts on racialized and low-income pregnant people.Qualitative strand: Understand how pregnant people's perceptions of COVID-19 risk influenced their decision-making about vaccination, perinatal care, social support, and mental health. METHODS AND ANALYSIS: This is a Canadian convergent parallel mixed-methods study. The quantitative strand uses a retrospective cohort design to assess birth group differences in rates of Tdap and COVID-19 vaccination, gestational diabetes screening, length of post-partum hospital stay, and onset of depression, anxiety, and adjustment disorder, using administrative data from ICES, formerly the Institute for Clinical Evaluative Sciences (Ontario) and PopulationData BC (PopData) (British Columbia). Differences by socioeconomic and ethnocultural status will also be examined. The qualitative strand employs qualitative description to interview people who gave birth between May 2020- December 2021 about their COVID-19 risk perception and health decision-making process. Data integration will occur during design and interpretation. ETHICS AND DISSEMINATION: This study received ethical approval from McMaster University and the University of British Columbia. Findings will be disseminated via manuscripts, presentations, and patient-facing infographics. TRIAL REGISTRATION: Registration: Clinicaltrials.gov registration number: NCT05663762.

Association between chronic conditions and urinary incontinence in females: a cross-sectional study using national survey data.

BACKGROUND: Urinary incontinence affects up to half of women, yet few speak to their health care provider about or receive treatment for the condition. To aid with identifying subpopulations at risk for urinary incontinence, we examined the associations between 10 chronic health conditions and urinary incontinence among Canadian adult females. METHODS: We conducted a cross-sectional analysis of survey data from the Canadian Community Health Survey (2013-2014) involving female respondents aged 25 years or older living in a private dwelling. Presence of chronic conditions and urinary incontinence were measured by self-report. We used logistic regression modelling with sampling weights, controlling for age, income, ethnicity, body mass index and smoking. Multiple imputation and probabilistic bias analysis were used to address missing covariate data and unmeasured confounding from parity. RESULTS: Our analysis included 60 186 respondents representing more than 12 million Canadian females, of whom 45.8% (95% confidence interval [CI] 45.0%-46.6%) reported at least 1 chronic condition. Chronic conditions were associated with more than twice the odds of urinary incontinence (adjusted odds ratio [OR] 2.42, 95% CI 2.02-2.89). Associations were largest for bowel disorders (adjusted OR 2.92, 95% CI 2.44-3.49); modest for chronic obstructive pulmonary disease (adjusted OR 2.00, 95% CI 1.63-2.45), asthma (adjusted OR 1.82, 95% CI 1.52-2.19), arthritis (adjusted OR 1.98, 95% CI 1.74-2.24) and heart disease (adjusted OR 1.73, 95% CI 1.48-2.02); and smallest for diabetes (adjusted OR 1.20, 95% CI 1.02-1.41) and high blood pressure (adjusted OR 1.27, 95% CI 1.12-1.44). Results slightly attenuated but did not substantively change after imputation and bias analysis. INTERPRETATION: We found that chronic conditions are associated with significantly higher odds of comorbid urinary incontinence among Canadian adult females, which is consistent with previous research. Our findings support routine inquiry regarding urinary incontinence symptoms among women accessing health care for chronic conditions.

Birth outcomes, pregnancy complications, and postpartum mental health after the 2013 Calgary flood: A difference in difference analysis.

BACKGROUND: In June 2013, the city of Calgary, Alberta and surrounding areas sustained significant flooding which resulted in large scale evacuations and closure of businesses and schools. Floods can increase stress which may negatively impact perinatal outcomes and mental health, but previous research is inconsistent. The objectives of this study are to examine the impact of the flood on pregnancy health, birth outcomes and postpartum mental health. METHODS: Linked administrative data from the province of Alberta were used. Outcomes included preterm birth, small for gestational age, a new diagnoses of preeclampsia or gestational hypertension, and a diagnosis of, or drug prescription for, depression or anxiety. Data were analyzed using a quasi-experimental difference in difference design, comparing flooded and non-flooded areas and in affected and unaffected time periods. Multivariable log binomial regression models were used to estimate risk ratios, adjusted for maternal age. Marginal probabilities for the difference in difference term were used to show the potential effect of the flood. RESULTS: Participants included 18,266 nulliparous women for the pregnancy outcomes, and 26,956 women with infants for the mental health analysis. There were no effects for preterm birth (DID 0.00, CI: -0.02, 0.02), small for gestational age (DID 0.00, CI: -0.02, 0.02), or new cases of preeclampsia (DID 0.00, CI: -0.01, 0.01). There was a small increase in new cases of gestational hypertension (DID 0.02, CI: 0.01, 0.03) in flood affected areas. There were no differences in postpartum anxiety or depression prescriptions or diagnoses. CONCLUSION: The Calgary 2013 flood was associated with a minor increase in gestational hypertension and not other health outcomes. Universal prenatal care and magnitude of the disaster may have minimized impacts of the flood on pregnant women.