Diabetes mellitus in pregnancy across Canada.

BACKGROUND: Contemporary estimates of diabetes mellitus (DM) rates in pregnancy are lacking in Canada. Accordingly, this study examined trends in the rates of type 1 (T1DM), type 2 (T2DM) and gestational (GDM) DM in Canada over a 15-year period, and selected adverse pregnancy outcomes. METHODS: This study used repeated cross-sectional data from the Canadian Institute of Health Information (CIHI) hospitalization discharge abstract database (DAD). Maternal delivery records were linked to their respective birth records from 2006 to 2019. The prevalence of T1DM, T2DM and GDM were calculated, including relative changes over time, assessed by a Cochrane-Armitage test. Also assessed were differences between provinces and territories in the prevalence of DM. RESULTS: Over the 15-year study period, comprising 4,320,778 hospital deliveries in Canada, there was a statistically significant increase in the prevalence of GDM and T1DM and T2DM. Compared to pregnancies without DM, all pregnancies with any form of DM had higher rates of hypertension and Caesarian delivery, and also adverse infant outcomes, including major congenital anomalies, preterm birth and large-for-gestational age birthweight. CONCLUSION: Among 4.3 million pregnancies in Canada, there has been a rise in the prevalence of DM. T2DM and GDM are expected to increase further as more overweight women conceive in Canada.

Cannabis use in pregnancy and maternal and infant outcomes: A Canadian cross-jurisdictional population-based cohort study.

BACKGROUND: With the recent legalization of cannabis in Canada, there is an urgent need to understand the effect of cannabis use in pregnancy. Our population-based study investigated the effects of prenatal cannabis use on maternal and newborn outcomes, and modification by infant sex. METHODS: The cohort included 1,280,447 singleton births from the British Columbia Perinatal Data Registry, the Better Outcomes Registry & Network Ontario, and the Perinatal Program Newfoundland Labrador from April 1st, 2012 to March 31st, 2019. Logistic regression determined the associations between prenatal cannabis use and low birth weight, small-for-gestational age, large-for-gestational age, spontaneous and medically indicated preterm birth, very preterm birth, stillbirth, major congenital anomalies, caesarean section, gestational diabetes and gestational hypertension. Models were adjusted for other substance use, socio-demographic and-economic characteristics, co-morbidities. Interaction terms were included to investigate modification by infant sex. RESULTS: The prevalence of cannabis use in our cohort was approximately 2%. Prenatal cannabis use is associated with increased risks of spontaneous and medically indicated preterm birth (1.80[1.68-1.93] and 1.94[1.77-2.12], respectively), very preterm birth (1.73[1.48-2.02]), low birth weight (1.90[1.79-2.03]), small-for-gestational age (1.21[1.16-1.27]) and large-for-gestational age (1.06[1.01-1.12]), any major congenital anomaly (1.71[1.49-1.97]), caesarean section (1.13[1.09-1.17]), and gestational diabetes (1.32[1.23-1.42]). No association was found for stillbirth or gestational hypertension. Only small-for-gestational age (p = 0.03) and spontaneous preterm birth (p = 0.04) showed evidence of modification by infant sex. CONCLUSIONS: Prenatal cannabis use increases the likelihood of preterm birth, low birth weight, small-for-gestational age and major congenital anomalies with prenatally exposed female infants showing evidence of increased susceptibility. Additional measures are needed to inform the public and providers of the inherent risks of cannabis exposure in pregnancy.

Association of SARS-CoV-2 Infection During Pregnancy With Maternal and Perinatal Outcomes.

Importance: There are limited high-quality, population-level data about the effect of SARS-CoV-2 infection on pregnancy using contemporaneous comparator cohorts. Objectives: To describe maternal and perinatal outcomes associated with SARS-CoV-2 infection in pregnancy and to assess variables associated with severe disease in the pregnant population. Design, Setting, and Participants: CANCOVID-Preg is an observational surveillance program for SARS-CoV-2-affected pregnancies in Canada. This analysis presents exploratory, population-level data from 6 Canadian provinces for the period of March 1, 2020, to October 31, 2021. A total of 6012 pregnant persons with a positive SARS-CoV-2 polymerase chain reaction test result at any time in pregnancy (primarily due to symptomatic presentation) were included and compared with 2 contemporaneous groups including age-matched female individuals with SARS-CoV-2 and unaffected pregnant persons from the pandemic time period. Exposure: SARS-CoV-2 infection during pregnancy. Incident infections in pregnancy were reported to CANCOVID-Preg by participating provinces/territories. Main Outcomes and Measures: Maternal and perinatal outcomes associated with SARS-CoV-2 infection as well as risk factors for severe disease (ie, disease requiring hospitalization, admission to an intensive care unit/critical care unit, and/or oxygen therapy). Results: Among 6012 pregnant individuals with SARS-CoV-2 in Canada (median age, 31 [IQR, 28-35] years), the greatest proportion of cases were diagnosed at 28 to 37 weeks' gestation (35.7%). Non-White individuals were disproportionately represented. Being pregnant was associated with a significantly increased risk of SARS-CoV-2-related hospitalization compared with SARS-CoV-2 cases among all women aged 20 to 49 years in the general population of Canada (7.75% vs 2.93%; relative risk, 2.65 [95% CI, 2.41-2.88]) as well as an increased risk of intensive care unit/critical care unit admission (2.01% vs 0.37%; relative risk, 5.46 [95% CI, 4.50-6.53]). Increasing age, preexisting hypertension, and greater gestational age at diagnosis were significantly associated with worse maternal outcomes. The risk of preterm birth was significantly elevated among SARS-CoV-2-affected pregnancies (11.05% vs 6.76%; relative risk, 1.63 [95% CI, 1.52-1.76]), even in cases of milder disease not requiring hospitalization, compared with unaffected pregnancies during the same time period. Conclusions and Relevance: In this exploratory surveillance study conducted in Canada from March 2020 to October 2021, SARS-CoV-2 infection during pregnancy was significantly associated with increased risk of adverse maternal outcomes and preterm birth.

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.

Stillbirth in Canada: anachronistic definition and registration processes impede public health surveillance and clinical care.

The archaic definition and registration processes for stillbirth currently prevalent in Canada impede both clinical care and public health. The situation is fraught because of definitional problems related to the inclusion of induced abortions at ≥20 weeks' gestation as stillbirths: widespread uptake of prenatal diagnosis and induced abortion for serious congenital anomalies has resulted in an artefactual temporal increase in stillbirth rates in Canada and placed the country in an unfavourable position in international (stillbirth) rankings. Other problems with the Canadian stillbirth definition and registration processes extend to the inclusion of fetal reductions (for multi-fetal pregnancy) as stillbirths, and the use of inconsistent viability criteria for reporting stillbirth. This paper reviews the history of stillbirth registration in Canada, provides a rationale for updating the definition of fetal death and recommends a new definition and improved processes for fetal death registration. The recommendations proposed are intended to serve as a starting point for reformulating issues related to stillbirth, with the hope that building a consensus regarding a definition and registration procedures will facilitate clinical care and public health.

RéSUMé: La définition et les méthodes d'enregistrement archaïques des mortinaissances qui prévalent actuellement au Canada entravent à la fois les soins cliniques et la santé publique. La situation est délicate à cause des problèmes de définition que pose l'inclusion des avortements provoqués à ≥ 20 semaines de gestation parmi les mortinaissances : le recours généralisé au diagnostic prénatal et les avortements provoqués en cas d'anomalies congénitales graves ont entraîné une augmentation temporelle artéfactuelle des taux de mortinatalité au Canada et placé le pays dans une position défavorable dans les classements internationaux (de la mortinatalité). Les autres problèmes dans la définition et les méthodes d'enregistrement canadiennes des mortinaissances sont l'inclusion de la réduction fœtale (pour les grossesses multifœtales) parmi les mortinaissances et l'emploi de critères de viabilité inconsistants pour déclarer les mortinaissances. Nous examinons ici l'histoire de l'enregistrement des mortinaissances au Canada, nous justifions une révision possible de la définition de la mort fœtale et nous recommandons une nouvelle définition et des méthodes d'enregistrement améliorées des morts fœtales. Les recommandations proposées se veulent un point de départ à une reformulation des questions liées à la mortinatalité, dans l'espoir que l'établissement d'un consensus sur une définition et sur les méthodes d'enregistrement facilitera les soins cliniques et la santé publique.

Effects of Delayed Newborn Bathing on Breastfeeding, Hypothermia, and Hypoglycemia.

OBJECTIVE: To determine whether delaying the newborn bath by 24 hours increases the prevalence of breastfeeding initiation and exclusive breastfeeding at discharge in healthy full-term and late preterm newborns (34 0/7-36 6/7 weeks gestation) and to examine the effect of delayed newborn bathing on the incidences of hypothermia and hypoglycemia. DESIGN: Pre-post implementation, retrospective, cohort study. SETTING: Provincial children's hospital with an average of 2,500 births per year. PARTICIPANTS: Healthy newborns (N = 1,225) born at 34 0/7 weeks or more gestation who were admitted to the mother-baby unit. METHODS: We compared newborns who were bathed before 24 hours (n = 680, preimplementation group) to newborns who were bathed after 24 hours (n = 545, postimplementation group). RESULTS: After adjustment for confounders, the odds of exclusive breastfeeding at discharge were 33% greater in the postimplementation group than in the preimplementation group (adjusted odds ratio = 1.334; 95% confidence interval [1.049,1.698]; p = .019). Delayed bathing was associated with decreased incidence of hypothermia and hypoglycemia (p = .007 and p = .003, respectively). We observed no difference in breastfeeding initiation between groups. CONCLUSION: Delaying the newborn bath for 24 hours was associated with an increased likelihood of exclusive breastfeeding at discharge and a decreased incidence of hypothermia and hypoglycemia in healthy newborns. The implementation of a delayed bathing policy has the potential to improve breastfeeding rates and reduce the incidence of hypothermia and hypoglycemia.

Severe maternal morbidity surveillance: Monitoring pregnant women at high risk for prolonged hospitalisation and death.

BACKGROUND: There is no international consensus on the definition and components of severe maternal morbidity (SMM). OBJECTIVES: To propose a comprehensive definition of SMM, to create an empirically justified list of SMM types and subtypes, and to use this to examine SMM in Canada. METHODS: Severe maternal morbidity was defined as a set of heterogeneous maternal conditions known to be associated with severe illness and with prolonged hospitalisation or high case fatality. Candidate SMM types/subtypes were evaluated using information on all hospital deliveries in Canada (excluding Quebec), 2006-2015. SMM rates for 2012-2016 were quantified as a composite and as SMM types/subtypes. Rate ratios and population attributable fractions (PAF) associated with overall and specific SMM types/subtypes were estimated in relation to length of hospital stay (LOS > 7 days) and case fatality. RESULTS: There were 22 799 cases of SMM subtypes (among 1 418 545 deliveries) that were associated with a prolonged LOS or high case fatality. Between 2012 and 2016, the composite SMM rate was 16.1 (95% confidence interval [CI] 15.9, 16.3) per 1000 deliveries. Severe pre-eclampsia and HELLP syndrome (514.6 per 100 000 deliveries), and severe postpartum haemorrhage (433.2 per 100 000 deliveries) were the most common SMM types, while case fatality rates among SMM subtypes were highest among women who had cardiac arrest and resuscitation (241.1 per 1000), hepatic failure (147.1 per 1000), dialysis (67.6 per 1000), and cerebrovascular accident/stroke (51.0 per 1000). The PAF for prolonged hospital stay related to SMM was 17.8% (95% CI 17.3, 18.3), while the PAF for maternal death associated with SMM was 88.0% (95% CI 74.6, 94.4). CONCLUSIONS: The proposed definition of SMM and associated list of SMM subtypes could be used for standardised SMM surveillance, with rate ratios and PAFs associated with specific SMM types/subtypes serving to inform clinical practice and public health policy.

The Rates of Any Breastfeeding at the Time of Postpartum Hospital Discharge for Early Term (370-386 Weeks) Versus Full Term (390-416 Weeks) Infants.

OBJECTIVE: This study sought to compare the rates of any breastfeeding between early term (370-386 weeks) and full term (390-416 weeks) infants at the time of postpartum hospital discharge. METHODS: A retrospective cohort study of women with live, singleton pregnancies who were delivered in St. John's, Newfoundland and Labrador, between April 2001 and March 2018 was completed. The primary outcome was any breastfeeding at the time of postpartum hospital discharge. Secondary analyses included a comparison of breastfeeding by week of gestational age at term and by maternal and neonatal demographics and outcomes of pregnancy. Univariate and multiple logistic regression analyses were performed. RESULTS: A total of 34 511 women were included. Early term infants were less likely to be breastfed than were full-term infants (67.9 vs. 70.4%) (adjusted odds ratio [aOR] 0.91; 95% confidence interval [CI] 0.86-0.97). Multiple logistic regression analysis also showed a significant effect of maternal age (aOR 1.07; 95% CI 1.05-1.09), partner status (aOR 1.56; 95% CI 1.20-2.03), smoking (aOR 0.32; 95% CI 0.26-0.41), prenatal education (aOR 2.43; 95% CI 1.99-2.97), pre-pregnancy body mass index (kg/m2) (aOR 0.97; 95% CI 0.96-0.98), and cesarean section (aOR 0.72; 95% CI 0.60-0.88). When compared by week of gestational age at term, the likelihood of breastfeeding significantly increased with each successive week (aOR 1.08; 95% CI 1.007-1.16). CONCLUSION: Early term delivery is an independent risk factor for not breastfeeding at the time of postpartum hospital discharge. It is important to target and support these women to increase breastfeeding rates. Additionally, these findings further validate recommendations to avoid non-medically indicated early term deliveries because of the increased risks of adverse outcomes.

Severe Maternal Morbidity in Canada: Temporal Trends and Regional Variations, 2003-2016.

OBJECTIVE: This study sought to quantify temporal trends and provincial and territorial variations in severe maternal morbidity (SMM) in Canada. METHODS: The study used data on all hospital deliveries in Canada (excluding Québec) from 2003 to 2016 to examine temporal trends and from 2012 to 2016 to study regional variations. SMM was identified using diagnosis and intervention codes. Contrasts among periods and regions were quantified using rate ratios (RRs) and 95% confidence intervals (CIs). Temporal changes were also assessed using chi-square tests for trend (Canadian Task Force Classification II-1). RESULTS: The study population included 3 882 790 deliveries between 2003 and 2016 and 1 418 545 deliveries between 2012 and 2016. Severe hemorrhage rates increased from 44.8 in 2003 to 62.4 per 10 000 deliveries in 2012 (P for trend <0.0001) and then declined to 41.8 per 10 000 deliveries in 2016 (P for trend <0.0001). Maternal intensive care unit admission and sepsis rates decreased between 2003 and 2016, whereas rates of stroke, severe uterine rupture, hysterectomy, obstetric embolism, shock, and assisted ventilation increased. Rates of composite SMM in 2012-2016 were higher in Newfoundland and Labrador (RR 1.15; 95% CI 1.04-1.26), Nova Scotia (RR 1.11; 95% CI 1.03-1.19), New Brunswick (RR1.22; 95% CI 1.13-1.32), Manitoba (RR 1.09; 95% CI 1.03-1.15), Saskatchewan (RR 1.15; 95% CI 1.09-1.22), the Yukon (RR 1.74; 95% CI 1.35-2.25), and Nunavut (RR 1.76; 95% CI 1.46-2.11) compared with the rest of Canada, whereas rates were lower in Alberta and British Columbia. CONCLUSION: This surveillance report helps inform clinical practice and public health policy for improving maternal health in Canada.

Interprovincial variation in pre-pregnancy body mass index and gestational weight gain and their impact on neonatal birth weight with respect to small and large for gestational age.

OBJECTIVES: To explore provincial variation in both excess and inadequate pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) and their impact on small- and large-for-gestational-age (SGA, LGA) infants. METHODS: Four provinces with a perinatal database capturing the required exposures participated: British Columbia (BC), Ontario (ON), Nova Scotia (NS), and Newfoundland and Labrador (NL). In multiple, concurrent retrospective studies, we included women ≥ 19 years, who gave birth from 22+0 to 42+6 weeks' gestation, to a live singleton from April 2013-March 2014. From adjusted odds ratios, we calculated population attributable fractions (PAF) of SGA and LGA for BMI and GWG. RESULTS: The proportion of overweight and obese women increased from western to eastern Canada. In BC, ON, NS, and NL, the proportions of women who were overweight were 21.1%, 24.0%, 23.7%, and 25.4%, while obesity proportions were 14.2%, 18.1%, 24.2%, and 29.8%, respectively. Excess GWG affected 53.9%, 49.9%, 57.6%, and 65.6% of women, respectively. Excess GWG contributed to 29.5-42.5% of LGA, compared with the PAFs for overweight (6.8-12.0%) and obesity (13.2-20.6%). Inadequate GWG's contribution to SGA (4.8-12.3%) was higher than underweight BMI's (2.9-6.2%). CONCLUSION: In this interprovincial study, high and increasing proportions of women from west to east had excess pre-pregnancy BMI, and between half to two thirds had excess GWG. The contributions of GWG outside of recommendations to SGA and LGA were greater than that of low or high BMI. GWG is a potentially modifiable determinant of SGA and LGA across Canada.

Are There Differences between Women who Choose Elective Repeat Caesarean Versus Trial of Labour in St. John's, NL?

OBJECTIVES: To compare the demographic and clinical characteristics between women who chose elective repeat Caesarean section (ERCS) versus trial of labour after Caesarean section (TOLAC) in St. John's, Newfoundland and Labrador (NL). METHODS: We conducted a retrospective case control study of women with live singleton gestations delivering at term in St. John's, NL between January 1, 2001 and December 31, 2014. Inclusion criteria were women who had a previous single lower segment Caesarean section (LSCS). TOLAC, successful TOLAC, and VBAC rates were calculated. Demographic and clinical characteristics were compared between women who chose ERCS versus TOLAC. Univariate analyses and multiple logistic regression analyses were performed, and adjusted odds ratios (aOR) and 95% CIs were calculated. RESULTS: A total of 1579 women were included, of whom 160 (10.1%) chose TOLAC, with 107 resulting in successful VBAC (67% successful TOLAC rate). The overall VBAC rate was 6.8%. Women who chose ERCS compared with those who chose TOLAC were more likely to be obese (aOR 3.20, 95% CI 1.85-5.54, P < 0.001), less likely to have had GA at delivery greater than 40 weeks (aOR 0.13, 95% CI 0.08-0.21, P < 0.001), less likely to have had a previous vaginal delivery (aOR 0.40, 95% CI 0.20-0.80, P < 0.001), and less likely to have had the previous CS for breech presentation (aOR 0.51, 95% CI 0.33-0.80, P = 0.003). CONCLUSIONS: The overall TOLAC and VBAC rates in St. John's are low when compared with reported national rates. The successful TOLAC rate is within the expected range reported in the literature. Differences exist between women who chose ERCS compared with TOLAC.

A comparison of breastfeeding rates by obesity class.

PURPOSE: The purpose of this study is to compare breastfeeding initiation rates for women across body mass index (BMI) classes, including normal BMI (18.50-24.99 kg/m2), overweight (25.00-29.99 kg/m2), obese (30.00-39.99 kg/m2), morbidly obese (40.00-49.99 kg/m2) and extreme obesity (≥50.00 kg/m2). MATERIALS AND METHODS: Retrospective cohort of women with singleton pregnancies, delivering in St. John's, NL between 2002 and 2011. The primary outcome was any breastfeeding on hospital discharge. Breastfeeding rates across BMI categories were compared, using univariate analyses. Multivariate analysis included additional maternal and obstetric variables. RESULTS: Twelve thousand four hundred twenty-two women were included: 8430 breastfed and 3992 did not breastfeed on hospital discharge. Progressively decreasing rates of breastfeeding were noted with increasing obesity class: normal BMI (71.1%), overweight (69.1%), obese (61.6%), morbidly obese (54.2%), and extremely obese women (42.3%). Multivariate analysis confirmed that increasing obesity class resulted in lower odds of breastfeeding: overweight (adjusted odds ratios (aOR) 0.86, 95%CI 0.76-0.98), obese (aOR 0.65, 95%CI 0.57-0.74), morbidly obese (aOR 0.57, 95%CI 0.44-0.74), and extreme obesity (aOR 0.37, 95%CI 0.19-0.74). CONCLUSION: Women in higher obesity classes are progressively less likely to initiate breastfeeding. Women with the highest prepregnancy BMIs should be particularly counseled on the benefits of breastfeeding.

The Impact of Maternal Obesity on Breastfeeding.

OBJECTIVE: To compare the rate of any breastfeeding at the time of postpartum hospital discharge between obese women (BMI ≥ 30.00 kg/m(2)) and women with a normal BMI (18.50 to 24.99 kg/m(2)). METHODS: We conducted a retrospective cohort study of women with live, singleton pregnancies who delivered in St. John's, Newfoundland and Labrador between 2002 and 2011, using data from the Newfoundland and Labrador provincial perinatal registry. The primary outcome was any breastfeeding at the time of discharge from hospital. Secondary analysis included comparison of breastfeeding rates by class of obesity. We compared additional maternal and neonatal outcomes between women who were breastfeeding at discharge and those who were not. Univariate and multivariate logistic regression analyses were performed, and adjusted odds ratios (aORs) and 95% CIs were calculated. RESULTS: We included 12 831 women with BMI data available in the study: 8676 were breastfeeding and 4155 were not at the time of postpartum discharge. Obese women were less likely to breastfeed than women with normal weight (60.0% vs. 71.7%) (aOR 0.63; 95% CI 0.55 to 0.71). Multivariate analysis showed a significant effect on the primary outcome of a mother's age (aOR 1.03; 95% CI 1.02 to 1.05), nulliparity (aOR 1.73; 95% CI 1.51 to 1.98), being partnered (aOR 1.57; 95% CI 1.34 to 1.84), working (aOR 1.10; 95% CI 1.02 to 1.19), having higher education (aOR 1.48; 95% CI 1.38 to 1.60), smoking (aOR 0.35; 95% CI 0.29 to 0.43), having gestational diabetes (aOR 0.70; 95% CI 0.5 to 0.92), pre-existing hypertension (aOR 0.58; 95% CI 0.39 to 0.87), gestational hypertension (aOR 0.67; 95% CI 0.55 to 0.82), and undergoing general anaesthesia (aOR 0.41; 95% CI 0.22 to 0.77). CONCLUSION: Obesity is an independent risk factor for not breastfeeding at the time of postpartum discharge from hospital. It is important to counsel women on the benefits of breastfeeding, emphasizing these particularly in women with a high pre-pregnancy BMI.

Maternal and perinatal outcomes of extreme obesity in pregnancy.

OBJECTIVE: To evaluate the effects of extreme obesity (pre-pregnancy BMI ≥ 50.0 kg/m2) in pregnancy on maternal and perinatal outcomes. METHODS: We conducted a population-based cohort study using the Newfoundland and Labrador Perinatal Database to compare obstetric outcomes in women with extreme obesity and those with a normal BMI (pre-pregnancy BMI 18.50 to 24.99 kg/m2). We included women with singleton gestations who gave birth between January 1, 2002, and December 31, 2011. Maternal outcomes of interest included gestational hypertension, gestational diabetes, Caesarean section, shoulder dystocia, length of hospital stay, maternal ICU admission, postpartum hemorrhage, and death. Perinatal outcomes included birth weight, preterm birth, Apgar score, neonatal metabolic abnormality, NICU admission, stillbirth, and neonatal death. A composite morbidity outcome was developed including at least one of Caesarean section, gestational hypertension, birth weight ≥ 4000 g, birth weight < 2500 g, or NICU admission. Univariate analyses and multivariate logistic regression analyses (controlling for maternal age, parity, smoking, partner status, and gestational age) were performed, and adjusted odds ratios (aORs) and 95% confidence intervals were calculated. RESULTS: A total of 5788 women were included in the study: 71 with extreme obesity and 5717 with a normal BMI. Extremely obese women were more likely to have gestational hypertension (19.7% vs. 4.8%) (aOR 1.56; 95% CI 1.33 to 1.82), gestational diabetes (21.1% vs. 1.5%) (aOR 2.04; 95% CI 1.74 to 2.38), shoulder dystocia (7.1% vs. 1.4%) (aOR 1.51; 95% CI 1.05 to 2.19), Caesarean section (60.6% vs. 25.0%) (aOR 1.46; 95% CI 1.29 to 1.65), length of hospital stay more than five days (excluding Caesarean section) (14.3% vs. 4.7%) (aOR 1.42; 95% CI 1.07 to 1.89), birth weight ≥ 4000 g (38.0% vs. 11.9%) (aOR 1.58; 95% CI 1.38 to 1.80), birth weight ≥ 4500 g (16.9% vs. 2.1%) (aOR 1.87; 95% CI 1.57 to 2.23), neonatal metabolic abnormality (8.5% vs. 2.0%) (aOR 1.50; 95% CI 1.20 to 1.86), NICU admission (16.9% vs. 7.8%) (aOR 1.28; 95% CI 1.07 to 1.52), stillbirth (1.4% vs. 0.2%) (aOR 1.68; 95% CI 1.00 to 2.82) and composite adverse outcome (81.7% vs. 41.5%) (aOR 1.57; 95% CI 1.35 to 1.83). CONCLUSION: Women with extreme obesity have increased risks of a variety of adverse maternal and perinatal outcomes. As approximately 6 per 1000 women giving birth in our population have extreme obesity, it is important to address these risks pre-conceptually and encourage a healthier BMI before pregnancy.

Objectif : Évaluer les effets de l'obésité extrême (IMC prégrossesse ≥ 50,0 kg/m2) pendant la grossesse sur les issues maternelles et périnatales. Méthodes : Nous avons mené une étude de cohorte en population générale au moyen de la Newfoundland and Labrador Perinatal Database en vue de comparer les issues obstétricales des femmes présentant une obésité extrême à celles des femmes dont l'IMC est normal (IMC prégrossesse allant de 18,50 à 24,99 kg/m2). Nous avons inclus les femmes qui connaissaient une grossesse monofœtale et qui ont accouché entre le 1er janvier 2002 et le 31 décembre 2011. Parmi les issues maternelles d'intérêt, on trouvait l'hypertension gestationnelle, le diabète gestationnel, la césarienne, la dystocie de l'épaule, la durée de l'hospitalisation, l'admission à l'unité maternelle de soins intensifs, l'hémorragie postpartum et la mort. Parmi les issues périnatales, on trouvait le poids de naissance, l'accouchement préterme, l'indice d'Apgar, les anomalies métaboliques néonatales, l'admission à l'UNSI, la mortinaissance et le décès néonatal. Une issue composite en matière de morbidité a été élaborée; on y retrouve au moins un des facteurs suivants : césarienne, hypertension gestationnelle, poids de naissance ≥ 4 000 g, poids de naissance < 2 500 g ou admission à l'UNSI. Des analyses univariées et des analyses de régression logistique multivariée (neutralisant l'effet de l'âge maternel, de la parité, du tabagisme, de l'état quant à la présence ou non d'un partenaire et de l'âge gestationnel) ont été menées, et des rapports de cotes corrigés (RCc) et des intervalles de confiance à 95 % ont été calculés. Résultats : Au total, 5 788 femmes ont été incluses à l'étude : 71 présentant une obésité extrême et 5 717 présentant un IMC normal. Les femmes extrêmement obèses étaient plus susceptibles de connaître ce qui suit : hypertension gestationnelle (19,7 % vs 4,8 %) (RCc 1,56; IC à 95 %, 1,33 - 1,82), diabète gestationnel (21,1 % vs 1,5 %) (RCc 2,04; IC à 95 %, 1,74 - 2,38), dystocie de l'épaule (7,1 % vs 1,4 %) (RCc 1,51; IC à 95 %, 1,05 - 2,19), césarienne (60,6 % vs 25,0 %) (RCc 1,46; IC à 95 %, 1,29 - 1,65), hospitalisation de plus de cinq jours (cas de césarienne exclus) (14,3 % vs 4,7 %) (RCc 1,42; IC à 95 %, 1,07 - 1,89), poids de naissance ≥ 4 000 g (38,0 % vs 11,9 %) (RCc 1,58; IC à 95 %, 1,38 - 1,80), poids de naissance ≥ 4 500 g (16,9 % vs 2,1 %) (RCc 1,87; IC à 95 %, 1,57 - 2,23), anomalie métabolique néonatale (8,5 % vs 2,0 %) (RCc 1,50; IC à 95 %, 1,20 - 1,86), admission à l'UNSI (16,9 % vs 7,8 %) (RCc 1,28; IC à 95 %, 1,07 - 1,52), mortinaissance (1,4 % vs 0,2 %) (RCc 1,68; IC à 95 %, 1,00 - 2,82) et issue indésirable composite (81,7 % vs 41,5 %) (RCc 1,57; IC à 95 %, 1,35 - 1,83). Conclusion : Les femmes qui présentent une obésité extrême sont exposées à des risques accrus de connaître une variété d'issues indésirables maternelles et périnatales. Puisque, au sein de notre population, environ six parturientes sur 1 000 présentent une obésité extrême, il est important de traiter de ces risques avant la conception et d'inciter les patientes à obtenir un IMC plus santé avant de devenir enceintes.

Examining caesarean section rates in Canada using the Robson classification system.

OBJECTIVE: To determine the groups within the obstetric population contributing most substantially to the Caesarean section rate in five Canadian provinces. METHODS: Hospital births from five participating provinces were grouped into Robson's 10 mutually exclusive and totally inclusive classification categories. The relative contribution of each group to the overall CS rate, relative size of group, and CS rate were calculated for British Columbia, Alberta, Ontario, Nova Scotia, and Newfoundland and Labrador for the four-year period from 2007-2008 to 2010-2011. RESULTS: In all five provinces (accounting for approximately 64% of births in Canada), and for all years examined, the group making the largest relative contribution to the CS rate was women with at least one previous CS and a term, singleton, cephalic-presenting pregnancy (Robson Group 5). The CS rate for this group ranged from 76.1% in Alberta to 89.9% in Newfoundland and Labrador in 2010 to 2011, accounting for 11.3% of all deliveries. The rate of CS for Group 5 decreased slightly over the four years, except in Ontario. The next largest contributing group was nulliparous women with a term, singleton, cephalic-presenting pregnancy. Those with induced labour or Caesarean section before labour (Robson Group 2) had CS rates ranging from 34.4% in Nova Scotia to 44.6% in British Columbia (accounting for 13.1% of all deliveries), and those with spontaneous onset of labour (Robson Group 1) had CS rates of 14.5% to 20.3% in 2010 to 2011 (accounting for 23.6% of all deliveries). CONCLUSION: All hospitals and health authorities can use this standardized classification system as part of a quality improvement initiative to monitor Caesarean section rates. This classification system identifies relevant areas for interventions and resources to reduce rates of Caesarean section.

The effect of gestational weight gain by body mass index on maternal and neonatal outcomes.

OBJECTIVE: To evaluate the effects of gestational weight gain on maternal and neonatal outcomes in different body mass index (BMI) classes. METHODS: We compared maternal and neonatal outcomes based on gestational weight gain in underweight, normal weight, overweight, obese, and morbidly obese (BMI>or=40.00) women. The study group was a population-based cohort of women with singleton gestations who delivered between April 1, 2001, and March 31, 2007, drawn from the Newfoundland and Labrador Provincial Perinatal Program Database. Univariate analyses and multivariate logistic regression analyses (controlling for maternal age, parity, smoking status, partnered status, and gestational age) were performed and odds ratios (ORs) were calculated. RESULTS: Only 30.6% of women gained the recommended amount of weight during pregnancy; 52.3% of women gained more than recommended, and 17.1% gained less than recommended. In women with normal pre-pregnancy BMI, excess weight gain was associated with increased rates of gestational hypertension (OR 1.27; 95% CI 1.08-1.49), augmentation of labour (OR 1.09; 95% CI 1.01-1.18), and birth weight>or=4000 g (OR 1.21; 95% CI 1.10-1.34). In overweight women, excess weight gain was associated with increased rates of gestational hypertension (OR 1.31; 95% CI 1.10-1.55) and birth weight>or=4000 g (OR 1.30; 95% CI 1.15-1.47). In women who were obese or morbidly obese, excess weight gain was associated with increased rates of birth weight>or=4000 g (OR 1.20; 95% CI 1.07-1.34) and neonatal metabolic abnormality (OR 1.31; 95% CI 1.00-1.70). In morbidly obese women, poor weight gain was associated with less use of epidural analgesia (OR 0.34; 95% CI 0.12-0.95). In women who were of normal weight, overweight, or obese, the rate of adverse outcome (Caesarean section, gestational hypertension, birth weight<2500 g or birth weight>or=4000 g) was lower in women with recommended weight gain than in those with excess weight gain. Adverse outcomes were reduced in nulliparous morbidly obese women who had poor weight gain (OR 0.18; 95% CI 0.04-0.83). CONCLUSION: The effects of gestational weight gain on pregnancy outcome depend on the woman's pre-pregnancy BMI. Pregnancy weight gains of 6.7-11.2 kg (15-25 lb) in overweight and obese women, and less than 6.7 kg (15 lb) in morbidly obese women are associated with a reduction in the risk of adverse outcome.