Gestational exposure to organochlorine compounds and metals and infant birth weight: effect modification by maternal hardships.

BACKGROUND: Gestational exposure to toxic environmental chemicals and maternal social hardships are individually associated with impaired fetal growth, but it is unclear whether the effects of environmental chemical exposure on infant birth weight are modified by maternal hardships. METHODS: We used data from the Maternal-Infant Research on Environmental Chemicals (MIREC) Study, a pan-Canadian cohort of 1982 pregnant females enrolled between 2008 and 2011. We quantified eleven environmental chemical concentrations from two chemical classes - six organochlorine compounds (OCs) and five metals - that were detected in ≥ 70% of blood samples collected during the first trimester. We examined fetal growth using birth weight adjusted for gestational age and assessed nine maternal hardships by questionnaire. Each maternal hardship variable was dichotomized to indicate whether the females experienced the hardship. In our analysis, we used elastic net to select the environmental chemicals, maternal hardships, and 2-way interactions between maternal hardships and environmental chemicals that were most predictive of birth weight. Next, we obtained effect estimates using multiple linear regression, and plotted the relationships by hardship status for visual interpretation. RESULTS: Elastic net selected trans-nonachlor, lead, low educational status, racially minoritized background, and low supplemental folic acid intake. All were inversely associated with birth weight. Elastic net also selected interaction terms. Among those with increasing environmental chemical exposures and reported hardships, we observed stronger negative associations and a few positive associations. For example, every two-fold increase in lead concentrations was more strongly associated with reduced infant birth weight among participants with low educational status (ß = -100 g (g); 95% confidence interval (CI): -215, 16), than those with higher educational status (ß = -34 g; 95% CI: -63, -3). In contrast, every two-fold increase in mercury concentrations was associated with slightly higher birth weight among participants with low educational status (ß = 23 g; 95% CI: -25, 71) compared to those with higher educational status (ß = -9 g; 95% CI: -24, 6). CONCLUSIONS: Our findings suggest that maternal hardships can modify the associations of gestational exposure to some OCs and metals with infant birth weight.

Oral Probiotic Supplementation in Pregnancy to Reduce Group B Streptococcus Colonisation (OPSiP trial): study protocol for a double-blind parallel group randomised placebo trial.

INTRODUCTION: Group B streptococcus (GBS), or Streptococcus agalactiae, remains a leading cause of neonatal morbidity and mortality. Canadian guidelines advise universal maternal screening for GBS colonisation in pregnancy in conjunction with selective antibiotic therapy. This results in over 1000 pregnant individuals receiving antibiotic therapy to prevent one case of early-onset neonatal GBS disease, and over 20 000 pregnant individuals receiving antibiotic therapy to prevent one neonatal death. Given the growing concern regarding the risk of negative sequela from antibiotic exposure, it is vital that alternative approaches to reduce maternal GBS colonisation are explored.Preliminary studies suggest some probiotic strains could confer protection in pregnancy against GBS colonisation. METHODS AND ANALYSIS: This double-blind parallel group randomised trial aims to recruit 450 pregnant participants in Vancouver, BC, Canada and will compare GBS colonisation rates in those who have received a daily oral dose of three strains of probiotics with those who have received a placebo. The primary outcome will be GBS colonisation status, measured using a vaginal/rectal swab obtained between 35 weeks' gestation and delivery. Secondary outcomes will include maternal antibiotic exposure and urogenital infections. Analysis will be on an intention-to-treat basis. PATIENT OR PUBLIC INVOLVEMENT: There was no patient or public involvement in the design of the study protocol. ETHICS AND DISSEMINATION: This study protocol received ethics approval from the University of British Columbia's Clinical Research Ethics Board, Dublin City University and Health Canada. Findings will be presented at research rounds, conferences and in peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT03407157.

Teaching by texting to promote positive health behaviours in pregnancy: a protocol for a randomised controlled trial of SmartMom.

INTRODUCTION: Prenatal education is associated with positive health behaviours, including optimal weight gain, attendance at prenatal care, acceptance of routine screening tests, smoking cessation, decreased alcohol consumption and breast feeding. Adoption of these behaviours has been associated with reduced rates of caesarean birth, preterm birth and low birth weight. Barriers to prenatal class attendance faced by parents in Canada include geography, socioeconomic status, age, education, and, among Indigenous peoples and other equity-deserving groups, stigma. To address the need for easily accessible and reliable information, we created 'SmartMom', Canada's first prenatal education programme delivered by short message service text messaging. SmartMom provides evidence-based information timed to be relevant to each week of pregnancy. The overall goal of SmartMom is to motivate the adoption of positive prenatal health behaviours with the ultimate goal of improving health outcomes among women and their newborns. METHODS AND ANALYSIS: We will conduct a two-arm single-blinded randomised controlled trial. Blinding of participants to trial intervention will not be possible as they will be aware of receiving the intervention, but data analysts will be blinded. Our primary research questions are to determine if women experiencing uncomplicated pregnancies randomly assigned to receive SmartMom messages versus messages addressing general topics related to pregnancy but without direction for behaviour change, have higher rates of: (1) weight gain within ranges recommended for prepregnancy body mass index and (2) adherence to Canadian guidelines regarding attendance at prenatal care appointments. ETHICS AND DISSEMINATION: The study has been granted a Certificate of Approval, number H22-00603, by the University of British Columbia Research Ethics Board. To disseminate our findings, we are undertaking both integrated and end-of-grant knowledge translation, which will proactively involve potential end-users and stakeholders at every phase of our project. TRIAL REGISTRATION NUMBER: NCT05793944.

Feasibility and acceptability of collecting umbilical cord tissue for prenatal cannabis research: A mixed-methods research study.

BACKGROUND: Large-scale longitudinal studies with biological samples are needed to examine the associations between prenatal cannabis use and birth and developmental outcomes. OBJECTIVES: The aim of this study was to understand the feasibility and acceptability of collecting umbilical cord tissue for the purpose of cannabis use testing in a community sample. DESIGN: This is a mixed methods research study consisted of a prospective cohort study and a qualitative descriptive study. METHODS: This study was conducted in Vancouver, British Columbia between January 2021 and August 2022. Participants were recruited during pregnancy, and the umbilical cord tissues were collected at birth and tested for the presence of cannabinoids. After the completion of the study, participants completed an online open-ended questionnaire about their overall experience. Data were analyzed using descriptive and thematic analyses. RESULTS: Among the 85 eligible individuals, 57 people (67%) consented to the study. The cord tissue was collected for 39 participants (68.4%). The collection rates for participants with vaginal, elective, and emergency cesarean delivery were 73.0%, 71.4%, and 53.8%, respectively, and for those with spontaneous and induced labor were 81.5% and 50%, respectively. Four (7.0%) and seven participants (12.3%) reported prenatal cannabis use in direct and probing self-report questions, respectively. The agreement between any self-report and cord tissue test was moderate (kappa 0.53, 95% confidence interval 0.06-0.99). Qualitative findings were classified into five themes. CONCLUSION: The collection of cord tissue was perceived acceptable by most participants. Implementation of collection protocols for complex labors, a central hospital unit to liaise direct communications and active participants' involvement might increase the feasibility of future studies.

Validating a predictive model for caesarean section in low-risk nulliparous pregnancies.

PROBLEM: Caesarean birth (CS) rates are steadily increasing. BACKGROUND: In 2017 Janssen et al. developed a model which could predict CB in nulliparous healthy woman with 71 % accuracy based on factors measurable on admission to the hospital. AIM: To validate the predictive model for risk of caesarean birth among low-risk, nulliparous women in a new setting. METHODS: A retrospective chart study in Abbotsford Regional Hospital (British Columbia, Canada) of healthy nulliparous women in spontaneous labour, at term, with a singleton fetus in cephalic position. Sociodemographic, pregnancy and labour-related characteristics were collected and independent predictors of CS were determined using multivariate logistic regression. The Janssen model was tested in the Abbotsford sample and additionally novel predictors were tested in an effort to improve the model. The area under the ROC curve (C-statistic) was computed and model calibration, sensitivity and specificity evaluated for the final model. FINDINGS AND DISCUSSION: Of 348 women, 106 (30.5 %) had a CB. Applying the Janssen predictive model to the Abbotsford data resulted in a C-statistic of 0.77. No new predictors were added to the model. The mean predicted risk score for CS in the cohort was 0.30 ± 0.20. A risk score cut-off of 0.32 was determined resulting in a sensitivity and specificity of 69 %. The model had acceptable calibration. CONCLUSION: A model with variables easily accessible at admission can predict caesarean birth in nulliparous women. The results from this study can guide provision of more intensive care during labour to women at higher risk, with the overall goal of reducing CB rates.

Oral micronized progesterone for perimenopausal night sweats and hot flushes a Phase III Canada-wide randomized placebo-controlled 4 month trial.

This study tested progesterone for perimenopausal hot flush ± night sweat (vasomotor symptom, VMS) treatment. It was a double-blind, randomized trial of 300 mg oral micronized progesterone@bedtime versus placebo for 3-months (m) after a 1-m untreated baseline during 2012/1-2017/4. We randomized untreated, non-depressed, screen- and baseline-eligible by VMS, perimenopausal women (with flow within 1-year), ages 35-58 (n = 189). Participants aged 50 (± SD = 4.6) were mostly White, educated, minimally overweight with 63% in late perimenopause; 93% participated remotely. The 1° outcome was 3rd-m VMS Score difference. Participants recorded VMS number and intensity (0-4 scale)/24 h on a VMS Calendar. Randomization required VMS (intensity 2-4/4) of sufficient frequency and/or ≥ 2/week night sweat awakenings. Baseline total VMS Score (SD) was 12.2 (11.3) without assignment difference. Third-m VMS Score did not differ by therapy (Rate Difference - 1.51). However, the 95% CI [- 3.97, 0.95] P = 0.222, did not exclude 3, a minimal clinically important difference. Women perceived progesterone caused decreased night sweats (P = 0.023) and improved sleep quality (P = 0.005); it decreased perimenopause-related life interference (P = 0.017) without increased depression. No serious adverse events occurred. Perimenopausal night sweats ± hot flushes are variable; this RCT was underpowered but could not exclude a minimal clinically important VMS benefit. Perceived night sweats and sleep quality significantly improved.

Pregnancy-Specific Anxiety Tool (PSAT): Instrument Development and Psychometric Evaluation.

Objective: Pregnancy-specific anxiety (PSA) is a distinct construct from general anxiety and depression. The purpose of this study was to develop, evaluate, and validate the Pregnancy-Specific Anxiety Tool (PSAT), to measure PSA and its severity.Methods: The study was carried out in 2 stages. Stage 1 involved item development and content and face validation. Stage 2 included psychometric evaluation to examine item distributions and correlational structure, dimensionality, internal consistency reliability, stability, and construct, convergent, and criterion validity, using 2 independent samples (initial sample N = 494, May-October 2018; validation sample N = 325, July 2019-May 2020).Results: Eighty-two items were evaluated for face validity and 41 items were considered in stage 2 based on feedback from participants and experts. Model fit from exploratory factor analysis and patterns of item-factor loadings suggested a 6-factor model with 33 items. The 6 factors included items pertaining to health and well-being of the baby, labor and the pregnant person's well-being, postpartum, support, career and finance, and indicators of severity. Confirmatory factor analysis carried out using the initial sample showed good fit with the validation sample. The area under the curve (AUC) for the diagnosis of adjustment disorders (AD) was 0.73 (95% CI, 0.67-0.79), and for AD/any anxiety disorders, the AUC was 0.80 (95% CI, 0.75-0.85).Conclusions: The PSAT can be useful for screening and monitoring of PSA, and pregnant people with scores higher than 10 should be considered for further assessment.

Expectant Parents' Preferences for Teaching by Texting: Development and Usability Study of SmartMom.

BACKGROUND: Prenatal education encourages healthy behavioral choices and reduces rates of adverse birth outcomes. The use of mobile health (mHealth) technologies during pregnancy is increasing and changing how pregnant people acquire prenatal education. SmartMom is an evidence-based prenatal education SMS text messaging program that overcomes barriers to prenatal class attendance, including rural or remote location, cost, stigma among participants, lack of instructors, and cessation of classes during the COVID-19 pandemic. OBJECTIVE: We sought to explore perceived information needs and preferences for the content and structure of prenatal education mHealth programs among persons enrolled in or eligible to enroll in SmartMom. METHODS: This was a qualitative focus group study conducted as part of a development and usability study of the SmartMom program. Participants were older than 19 years of age, Canadian residents, fluent in English, and either currently pregnant or pregnant within the last year. We asked open-ended questions about information-seeking behaviors during pregnancy, the nature of the information that participants were seeking, how they wanted to receive information, and if SmartMom was meeting these needs. Focus groups took place via videoconference technology (Zoom) between August and December 2020. We used reflexive thematic analysis to identify themes that emerged from the data and the constant comparison method to compare initial coding to emerging themes. RESULTS: We conducted 6 semistructured focus groups with 16 participants. All participants reported living with a partner and owning a cell phone. The majority (n=13, 81%) used at least 1 app for prenatal education. Our analysis revealed that "having reliable information is the most important thing" (theme 1); pregnant people value inclusive, local, and strength-based information (theme 2); and SMS text messages are a simple, easy, and timely modality ("It was nice to have that [information] fed to you"; theme 3). Participants perceived that SmartMom SMS text messages met their needs for prenatal education and were more convenient than using apps. SmartMom's opt-in supplemental message streams, which allowed users to tailor the program to their needs, were viewed favorably. Participants also identified that prenatal education programs were not meeting the needs of diverse populations, such as Indigenous people and LGBTQIA2S+ (lesbian, gay, bisexual, transgender, queer and/or questioning, intersex, asexual, Two-Spirit plus) communities. CONCLUSIONS: The shift toward digital prenatal education, accelerated by the COVID-19 pandemic, has resulted in a plethora of web- or mobile technology-based programs, but few of these have been evaluated. Participants in our focus groups revealed concerns about the reliability and comprehensiveness of digital resources for prenatal education. The SmartMom SMS text messaging program was viewed as being evidence-based, providing comprehensive content without searching, and permitting tailoring to individual needs through opt-in message streams. Prenatal education must also meet the needs of diverse populations.

The effect of changing screening practices and demographics on the incidence of gestational diabetes in British Columbia, 2005-2019.

BACKGROUND: Rates of gestational diabetes are reported to be increasing in many jurisdictions, but the reasons for this are poorly understood. We sought to evaluate the relative contribution of screening practices for gestational diabetes (including completion and methods of screening) and population characteristics to risk of gestational diabetes in British Columbia, Canada, from 2005 to 2019. METHODS: We used a population-based cohort from a provincial registry of perinatal data, linked to laboratory billing records. We used data on screening completion, screening method (1-step 75-g glucose test or 2-step approach of 50-g glucose screening test, followed by a diagnostic test for patients who screen positive) and demographic risk factors. We modelled predicted annual risk for gestational diabetes, sequentially adjusted for screening completion, screening method and risk factors. RESULTS: We included 551 457 pregnancies in the study cohort. The incidence of gestational diabetes more than doubled over the study period, from 7.2% in 2005 to 14.7% in 2019. Screening completion increased from 87.2% in 2005 to 95.5% in 2019. Use of 1-step screening methods increased from 0.0% in 2005 to 39.5% in 2019 among those who were screened. Unadjusted models estimated a 2.04 (95% confidence interval [CI] 1.94-2.13) increased risk of gestational diabetes in 2019 (v. 2005). This increase was 1.89 (95% CI 1.81-1.98) after accounting for the rise in screening completion and 1.34 (95% CI 1.28-1.40) after accounting for changes in screening methods. Further accounting for demographic risk factors (e.g., age, body mass index, prenatal care) had a small impact (increase of 1.25, 95% CI 1.19-1.31). INTERPRETATION: Most of the observed increase in the incidence of gestational diabetes was attributable to changes in screening practices (primarily changes in screening methods) rather than changing population factors. Our findings highlight the importance of understanding variation in screening practices when monitoring incidence rates for gestational diabetes.

Investigating the effect of early life antibiotic use on asthma and allergy risk in over 600 000 Canadian children: a protocol for a retrospective cohort study in British Columbia and Manitoba.

INTRODUCTION: Allergic conditions, such as asthma, hay fever and eczema, are some of the most common conditions impacting children globally. There is a strong incentive to study their determinants to improve their prevention. Asthma, hay fever and eczema are influenced through the same immunological pathway and often copresent in children ('the atopic march'). Increasing evidence shows a link between infant antibiotic use and the risk of childhood atopic conditions, mediated through gut microbial dysbiosis during immune system maturation, however, the potential for confounding remains. This study will investigate the relationship between infant antibiotic use and risk of allergic conditions in British Columbian and Manitoban children born over 10 years, adjusting for relevant confounders. METHODS AND ANALYSIS: Provincial administrative datasets will be linked to perform comparable retrospective cohort analyses, using Population Data BC and the Manitoba Population Research Data Repository. All infants born between 2001 and 2011 in BC and Manitoba will be included (approximately 460 000 and 162 500 infants, respectively), following up to age 7. Multivariable logistic regression will determine the outcome risk by the fifth birthday among children who did and did not receive antibiotics before their first birthday. Clinical, demographic and environmental covariates will be explored, and sensitivity analyses performed to reduce confounding by indication. ETHICS AND DISSEMINATION: The University of British Columbia Research Ethics Board (H19-03255) and University of Manitoba Ethics Board (HS25156 (H2021:328)) have approved this study. Data stewardship committees for all administrative datasets have granted permissions, facilitated by Population Data BC and the Manitoba Centre for Health Policy. Permissions from the Canadian Health Infant Longitudinal Development Study are being sought for breastfeeding data (CP185). Findings will be published in scientific journals and presented at infectious disease and respiratory health conferences. A stakeholder committee will guide and enhance sensitive and impactful communication of the findings to new parents.

Weight gain in pregnancy and infant birthweight after the onset of the COVID-19 pandemic: an interrupted time series analysis.

BACKGROUND: Increased weight gain and decreased physical activity have been reported in some populations since the coronavirus disease 2019 (COVID-19) pandemic, but this has not been well characterized in pregnant populations. OBJECTIVES: Our objective was to characterize the impact of the COVID-19 pandemic and associated countermeasures on pregnancy weight gain and infant birthweight in a US cohort. METHODS: Washington State pregnancies and births (1 January, 2016 to 28 December, 2020) from a multihospital quality improvement organization were examined for pregnancy weight gain, pregnancy weight gain z-score adjusted for pregestational BMI and gestational age, and infant birthweight z-score, using an interrupted time series design that controls for underlying time trends. We used mixed-effect linear regression models, controlled for seasonality and clustered at the hospital level, to model the weekly time trends and changes on 23 March, 2020, the onset of local COVID-19 countermeasures. RESULTS: Our analysis included 77,411 pregnant people and 104,936 infants with complete outcome data. The mean pregnancy weight gain was 12.1 kg (z-score: -0.14) during the prepandemic time period (March to December 2019) and increased to 12.4 kg (z-score: -0.09) after the onset of the pandemic (March to December 2020). Our time series analysis found that after the pandemic onset, the mean weight gain increased by 0.49 kg (95% CI: 0.25, 0.73 kg) and weight gain z-score increased by 0.080 (95% CI: 0.03, 0.13), with no changes in the baseline yearly trend. Infant birthweight z-scores were unchanged (-0.004; 95% CI: -0.04, 0.03). Overall, the results were unchanged in analyses stratified by pregestational BMI categories. CONCLUSIONS: We observed a modest increase in weight gain after the onset of the pandemic among pregnant people but no changes in infant birthweights. This weight change could be more important in high BMI subgroups.

Validation of Insurance Billing Codes for Monitoring Antenatal Screening.

BACKGROUND: Prevalence statistics for pregnancy complications identified through screening such as gestational diabetes usually assume universal screening. However, rates of screening completion in pregnancy are not available in many birth registries or hospital databases. We validated screening-test completion by comparing public insurance laboratory and radiology billing records with medical records at three hospitals in British Columbia, Canada. METHODS: We abstracted a random sample of 140 delivery medical records (2014-2019), and successfully linked 127 to valid provincial insurance billings and maternal-newborn registry data. We compared billing records for gestational diabetes screening, any ultrasound before 14 weeks gestational age, and Group B streptococcus screening during each pregnancy to the gold standard of medical records by calculating sensitivity and specificity, positive predictive value, negative predictive value, and prevalence with 95% confidence intervals (CIs). RESULTS: Gestational diabetes screening (screened vs. unscreened) in billing records had a high sensitivity (98% [95% CI = 93, 100]) and specificity (>99% [95% CI = 86, 100]). The use of specific glucose screening approaches (two-step vs. one-step) were also well characterized by billing data. Other tests showed high sensitivity (ultrasound 97% [95% CI = 92, 99]; Group B streptococcus 96% [95% CI = 89, 99]) but lower negative predictive values (ultrasound 64% [95% CI = 33, 99]; Group B streptococcus 70% [95% CI = 40, 89]). Lower negative predictive values were due to the high prevalence of these screening tests in our sample. CONCLUSIONS: Laboratory and radiology insurance billing codes accurately identified those who completed routine antenatal screening tests with relatively low false-positive rates.

Trends in Gestational Diabetes Screening Practices in British Columbia from 2005-2019.

OBJECTIVES: To examine trends in the frequency and method (one-step vs. two-step) of gestational diabetes mellitus (GDM) screening in British Columbia (BC), Canada, across subgroups of pregnant individuals in the context of changing local and national clinical practice guidelines. METHODS: We conducted a retrospective cohort study using de-identified, linked perinatal and laboratory billing data. We included all pregnancies delivered in BC after 28 weeks gestation, with screening dates between June 2004 and May 2019. We calculated the prevalence of each screening method with 95% CI overall and over time, and we examined screening practices in subgroups and different geographic regions. In October 2010, BC began recommending a one-step method; therefore, we examined time periods relative to this and other Canadian guideline changes. RESULTS: Screening completion increased over the study period, from 88% in 2004 to 96% in 2019. After a guideline change in 2010, use of one-step screening increased sharply from 2.0% (95% CI 1.9-2.0) to 45.2% (95% CI 44.9-45.6). Following the 2013 Diabetes Canada guideline change, one-step screening decreased to 42.8% (95% CI 42.5-43.1). Of those receiving one-step screening, 18% were diagnosed with GDM compared to 9% with two-step screening. Use of one-step screening was higher in pregnant people with risk factors and in larger urban centres. CONCLUSION: GDM screening in BC demonstrated higher use of one-step screening among people with risk factors; however, there were strong regional disparities and considerable variation in screening practices over time and across subgroups.

Survey of Mode of Delivery and Maternal and Perinatal Outcomes in Canada.

OBJECTIVE: To identify determinants of cesarean delivery (CD) and examine associations between mode of delivery (MOD) and maternal and perinatal outcomes. METHODS: We conducted a retrospective analysis of a Canadian multicentre birth cohort derived from provincial data collected in 2008/2009. Maternal and perinatal characteristics and outcomes were compared between vaginal and cesarean birth and between the following MOD subgroups: spontaneous vaginal delivery (VD), assisted VD, planned cesarean delivery (CD), and intrapartum CD. Multivariate regression identified determinants of CD and the effects of MOD and previous CD on maternal and perinatal outcomes. RESULTS: The cohort included 264 755 births (72.1% VD and 27.9% CD) from 91 participating institutions. Determinants of CD included maternal age, parity, previous CD, chronic hypertension, diabetes, urinary tract infection or pyelonephritis, gestational hypertension, vaginal bleeding, labour induction, pre-term gestational age, low birth weight, large for gestational age, malpresentation, and male sex. CD was associated with greater risk of maternal and perinatal morbidity and mortality. Subgroup analysis demonstrated higher risk of adverse pregnancy outcomes with assisted VD and intrapartum CD than spontaneous VD. Planned CD reduced the risk of obstetric wound hematoma and perinatal mortality but increased maternal and neonatal morbidity. Previous CD increased the risk of maternal and neonatal morbidity among multiparous women. CONCLUSIONS: The CD rate in Canada is consistent with global trends reflecting demographic and obstetric intervention factors. The risk of adverse pregnancy outcomes with CD warrants evaluation of interventions to safely prevent nonessential cesarean birth.

Higher Hospitalization Rates in Children Born HIV-exposed Uninfected in British Columbia, Canada, Between 1990 and 2012.

BACKGROUND: Compared with children who are HIV-unexposed and uninfected (CHUU), children who are HIV-exposed and uninfected (CHEU) experience more clinical complications. We investigated hospitalizations among CHEU by antenatal antiretroviral therapy (ART) exposure, in British Columbia, Canada. METHODS: This retrospective controlled cohort study used administrative health data from 1990 to 2012. CHEU and CHUU were matched 1:3 for age, sex and maternal geographical area of residence. We determined adjusted odds ratios (aORs) via conditional logistic regression, adjusting for maternal risk factors. RESULTS: A total of 446 CHEU and 1333 CHUU were included. Compared with CHUU, more CHEU experienced one or more lifetime hospitalization (47.3% vs. 29.8%), one or more neonatal hospitalization (40.4% vs. 27.6%), and any intensive care unit admission (28.5% vs. 9.2%). In adjusted analyses, CHEU experienced higher odds of any lifetime hospitalization (aOR 2.30, 95% confidence interval 1.81-2.91) and neonatal hospitalization (aOR 2.14, 95% confidence interval 1.68-2.73), compared with CHUU. There was, however, no difference in infection-related hospitalizations (9.0% vs. 7.5%), which were primarily respiratory tract infections among both CHEU and CHUU. CHEU whose mothers-initiated ART preconception showed lower odds of infection-related hospitalizations than children whose mothers initiated ART during pregnancy or received no ART. CONCLUSIONS: CHEU experienced increased odds of hospitalization relative to CHUU. A substantial number of CHEU hospitalizations occurred within the neonatal period and were ICU admissions. Initiating ART preconception may reduce the risk of infection-related hospitalizations. These findings reinforce the benefit of ART in pregnancy and the need for ongoing pediatric care to reduce hospitalizations.

Supporting population mental health and wellness during the COVID-19 pandemic in Canada: protocol for a sequential mixed-method study.

INTRODUCTION: The global COVID-19 pandemic has reported to have a negative impact on the mental health and well-being of individuals around the world. Mental health system infrastructure, primarily developed to support individuals through in-person care, struggled to meet rising demand for services even prior to COVID-19. With public health guidelines requiring the use of physical distancing during the pandemic, digital mental health supports may be one way to address the needs of the population. Despite this, barriers exist in promoting and supporting access to existing and emerging digital resources. Text messaging may address some of these barriers, extending the potential reach of these digital interventions across divides that may separate some vulnerable or disadvantaged groups from essential mental health supports. Building on an existing knowledge synthesis project identifying key digital resources for improved mental health, this research will establish low-tech connections to assess need and better match access to services for those who need it most. The aim of this study is to codesign a customised two-way texting service to explore need and better align access to mental health supports for Canadians located in Saskatchewan during the COVID-19 pandemic. METHODS AND ANALYSIS: This study will be completed in Saskatchewan, Canada. For this project, the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework will be used to support three phases of a sequential mixed-method study. An advisory committee of Saskatchewan residents will guide this work with the study team. A 10-week service will be launched to connect individuals with appropriately suited digital mental health interventions through the use of text messaging. In phase 1, implementation and prototyping will be conducted with collaborative codesign for key elements related to features of an enrolment survey and initial messaging content. Phase 2 will focus on advancing the effectiveness of the service using quantitative user data. In phase 3, an embedding approach will be used to integrate both qualitative and quantitative data collected to understand the overall acceptability, satisfaction and perceived benefit of the text messaging service. Thematic analysis and descriptive statistics will be used as analytic methods. ETHICS AND DISSEMINATION: This study has received approval from the Research Ethics Board at the University of Saskatchewan. A knowledge dissemination plan has been developed that includes traditional academic approaches such as conference presentations, and academic publications, as well as mainstream approaches such as social media, radio and dissemination through the advisory committee.