Patterns of social inequalities across pregnancy and birth outcomes: a comparison of individual and neighborhood socioeconomic measures.

BACKGROUND: This paper identifies patterns of health inequalities (consistency and magnitude) of socioeconomic disparities for multiple maternal and child health (MCH) outcomes that represent different health care needs of mothers and infants. METHODS: Using cross-sectional national data (unweighted sample = 6,421, weighted =76,508) from the Canadian Maternity Experiences Survey linked with 2006 Canadian census data, we categorized 25 health indicators of mothers of singletons into five groups of MCH outcomes (A. maternal and infant health status indicators; B. prenatal care; C. maternal experience of labor and delivery; D. neonatal medical care; and E. postpartum infant care and maternal perceptions of health care services). We then examined the association of these health indicators with individual socioeconomic position (SEP) (education and income), neighborhood SEP and combined SEP (a four-level measure of low and high individual and neighborhood SEP), and compared the magnitude (odds ratios and 95% confidence intervals) and direction of the associations within and between MCH outcome groups. RESULTS: We observed consistent positive gradients of socioeconomic inequalities within most groups and for 23/25 MCH outcomes. However, more significant associations and stronger gradients were observed for the MCH outcomes in the maternal and infant health status group as opposed to other groups. The neonatal medical care outcomes were weakly associated with SEP. The direction of associations was negative between some SEP measures and HIV testing, timing of the first ultrasound, caesarean section, epidural for vaginal births, infant needing non-routine neonatal care after discharge and any breastfeeding at 3 or 6 months. Gradients were steep for individual SEP but moderate for neighborhood SEP. Combined SEP had no consistent gradients but the subcategory of low individual-high neighborhood SEP often showed the poorest health outcomes compared to the categories within this SEP grouping. CONCLUSION: By examining SEP gradients in multiple MCH outcomes categorized into groups of health care needs, we identified large and consistent inequalities both within and between these groups. Our results suggest differences in pathways and mechanisms contributing to SEP inequalities across groups of MCH outcomes that can be examined in future research and inform prioritization of policies for reducing these inequalities.

Contribution of prepregnancy body mass index and gestational weight gain to adverse neonatal outcomes: population attributable fractions for Canada.

BACKGROUND: Low or high prepregnancy body mass index (BMI) and inadequate or excess gestational weight gain (GWG) are associated with adverse neonatal outcomes. This study estimates the contribution of these risk factors to preterm births (PTBs), small-for-gestational age (SGA) and large-for-gestational age (LGA) births in Canada compared to the contribution of prenatal smoking, a recognized perinatal risk factor. METHODS: We analyzed data from the Canadian Maternity Experiences Survey. A sample of 5,930 women who had a singleton live birth in 2005-2006 was weighted to a nationally representative population of 71,200 women. From adjusted odds ratios, we calculated population attributable fractions to estimate the contribution of BMI, GWG and prenatal smoking to PTB, SGA and LGA infants overall and across four obstetric groups. RESULTS: Overall, 6% of women were underweight (<18.5 kg/m(2)) and 34.4% were overweight or obese (≥25.0 kg/m(2)). More than half (59.4%) gained above the recommended weight for their BMI, 18.6% gained less than the recommended weight and 10.4% smoked prenatally. Excess GWG contributed more to adverse outcomes than BMI, contributing to 18.2% of PTB and 15.9% of LGA. Although the distribution of BMI and GWG was similar across obstetric groups, their impact was greater among primigravid women and multigravid women without a previous PTB or pregnancy loss. The contributions of BMI and GWG to PTB and SGA exceeded that of prenatal smoking. CONCLUSIONS: Maternal weight, and GWG in particular, contributes significantly to the occurrence of adverse neonatal outcomes in Canada. Indeed, this contribution exceeds that of prenatal smoking for PTB and SGA, highlighting its public health importance.

Socioeconomic position and factors associated with use of a nonsupine infant sleep position: findings from the Canadian Maternity Experiences Survey.

OBJECTIVES: With a focus on socioeconomic position, we examined the association between maternal education and nonsupine infant sleep position, and examined patterns of effect modification with additional sociodemographic, maternal, infant, and health services predictors. METHODS: Data were from the Maternity Experiences Survey, a national population-based sample of 76 178 new Canadian mothers (unweighted n = 6421) aged 15 years or older interviewed in 2006-2007. Using logistic regression, we developed multivariate models for 3 maternal education strata. RESULTS: Level of maternal education was significantly and inversely related to nonsupine infant sleep position. Stratified analyses revealed different predictive factors for nonsupine infant sleep position across strata of maternal education. Postpartum home visits were not associated with use of this sleep position among new mothers with less than high school completion. Adequacy of postpartum information regarding sudden infant death syndrome was not associated with nonsupine infant sleep position in any of the educational strata. CONCLUSIONS: These findings suggest a need to revisit Back to Sleep health promotion strategies and to ensure that these interventions are tailored to match the information needs of all families, including mothers with lower levels of formal education.

Contribution of prepregnancy body mass index and gestational weight gain to caesarean birth in Canada.

BACKGROUND: Overweight and obese women are known to be at increased risk of caesarean birth. This study estimates the contribution of prepregnancy body mass index (BMI) and gestational weight gain (GWG) to caesarean births in Canada. METHODS: We analyzed data from women in the Canadian Maternity Experiences Survey who had a singleton term live birth in 2005-2006. Adjusted odds ratios for caesarean birth across BMI and GWG groups were derived, separately for nulliparous women and parous women with and without a prior caesarean. Population attributable fractions of caesarean births associated with above normal BMI and excess GWG were calculated. RESULTS: The overall caesarean birth rate was 25.7%. Among nulliparous and parous women without a previous caesarean birth, rates in obese women were 45.1% and 9.7% respectively, and rates in women who gained above their recommended GWG were 33.5% and 8.0% respectively. Caesarean birth was more strongly associated with BMI than with GWG. However, due to the high prevalence of excess GWG (48.8%), the proportion of caesareans associated with above normal BMI and excess GWG was similar [10.1% (95% CI: 9.9-10.2) and 10.9% (95% CI: 10.7-11.1) respectively]. Overall, one in five (20.2%, 95% CI: 20.0-20.4) caesarean births was associated with above normal BMI or excess GWG. CONCLUSIONS: Overweight and obese BMI and above recommended GWG are significantly associated with caesarean birth in singleton term pregnancies in Canada. Strategies to reduce caesarean births must include measures to prevent overweight and obese BMI prior to conception and promote recommended weight gain throughout pregnancy.

Risk factors for preterm birth and small-for-gestational-age births among Canadian women.

BACKGROUND: Preterm births (PTB) and small-for-gestational-age (SGA) births are distinct but related pregnancy outcomes, with differing aetiologies and short and long-term morbidities. Few studies have compared a broad array of predictors among these two outcomes. The purpose of this study was to compare risk factors for PTB and SGA births using a national sample of Canadian women. METHODS: We analysed data from the Canadian Maternity Experiences Survey (n = 6421). Mothers were ≥ 15 years of age, gave birth to a singleton infant and were living with their infant at the time of the interview (between 5 and 14 months post-partum). Backward stepwise multivariable logistic regression models were constructed for each outcome. RESULTS: Risk profiles for the two outcomes had both differences and similarities. Risk factors specific to PTB were education less than high school, having a previous medical condition, developing a new medical condition or health problem during pregnancy, being a primigravida, or being a multigravida with a previous PTB or a previous miscarriage or abortion. Risk factors unique to SGA were low pre-pregnancy body mass index (<18 kg/m(2) ), smoking during pregnancy and being a recent immigrant. Risk factors for both outcomes included low weight gain during pregnancy (<9.1 kg), short stature (<155 cm) and reporting life as 'very stressful' in the year prior to birth of the baby. CONCLUSION: A greater understanding of the risk factors related to PTB and SGA may help to reduce the prevalence of these conditions and the associated risk of infant mortality and morbidity.

Childbirth across cultures: research and practice.

Countries and cultures differ in their approach to childbirth, as well as in their research practices. This paper examines 10 surveys of women's reports of their labor and birth in seven countries spanning North America and Western Europe and Eastern Europe. Similarities and differences in practice are highlighted, and the methodological difficulties of conducting research in cross-cultural settings are examined. This paper discusses innovative and culturally unique perinatal practices that are not revealed by such surveys and stresses the importance of sharing such ideas globally.

Rates of interventions in labor and birth across Canada: findings of the Canadian Maternity Experiences Survey.

BACKGROUND: Rates of interventions in labor and birth should be similar across a country if evidence-based practice guidelines are followed. This assumption is tested by comparison of some practices across the 13 provinces and territories of Canada. The objective of this study was to describe the wide provincial and territorial variations in rates of routine interventions and practices during labor and birth as reported by women in the Maternity Experiences Survey of the Canadian Perinatal Surveillance System. METHODS: A sample of 8,244 eligible women was identified from a randomly selected sample of recently born infants drawn from the May 2006 Canadian Census. The sample was stratified by province and territory. Computer-assisted telephone interviews were conducted with participating birth mothers by Statistics Canada on behalf of the Public Health Agency of Canada. Interviews took an average of 45 minutes and were completed when infants were between 5 and 10 months old (9-14 mo in the territories). Completed responses were obtained from 6,421 women (78%). RESULTS: Provincial and territorial variations in rates of routine intervention used during labor and birth are reported. The percentage range of mothers' experience of induction (range 30.9%), epidural (53.7%), continuous electronic fetal monitoring (37.9%), and medication-free pain management during labor (40.7%) are provided, in addition to the use of episiotomy (14.1%) or "stitches" (48.3%), being in a "flat lying position" (42.2%), and having their legs in stirrups for birth (35.7%). Wide variations in the use of most of the interventions were found, ranging from 14.1 percent to 53.7 percent. CONCLUSIONS: Rates of intervention in labor and birth showed considerable variation across Canada, suggesting that usage is not always evidence based but may be influenced by a variety of other factors.

The language of birth.

Our language both reflects and influences our attitudes and behavior. This Roundtable Discussion explores the language used in obstetrics and in the interactions between caregivers and women or their families: What do practitioners say to mothers and families during labor? At birth? In consultations? To describe what is happening? To encourage a woman's efforts? To lighten the atmosphere? When advising about possible interventions? Medical terminology in perinatal care can often be deceptive or confusing, not only for mothers but for caregivers. The authors of this Roundtable, representing health professionals from different specialties and interests in the field, have examined some examples of such language use, misuse, and abuse in perinatal care. (BIRTH 39:2 June 2012).

Factors associated with perceived stress and stressful life events in pregnant women: findings from the Canadian Maternity Experiences Survey.

Prenatal maternal stress has been linked to multiple adverse outcomes. Researchers have used a variety of methods to assess maternal stress. The purpose of this study was to explore and compare factors associated with stress in pregnancy as measured by perceived stress and stressful life events. We analyzed data from the Canadian Maternity Experiences Survey. A randomly selected sample of 8,542 women who had recently given birth was drawn from the 2006 Canadian Census. Women were eligible if they were at least 15 years of age, had delivered a live, singleton infant, and were living with their infant at the time of the interview (5-14 months postpartum). Prevalence estimates and odds ratios were calculated using sample weights of the survey and their variances were calculated using bootstrapping methods. Bivariate analyses identified statistically significant factors associated with each stress measure. Backward stepwise multivariate logistic regression models were constructed. A total of 6,421 women (78%) participated in the computer assisted telephone interview. Twelve percent of women experienced high levels of perceived stress and 17.1% reported having three or more stressful life events in the year prior to the birth of their baby. In the final model, psychosocial variables were associated with both outcomes, whereas demographic factors were associated only with life event stress. Different factors contributed to perceived stress and life event stress, suggesting that these concepts measure different aspects of stress. These findings can inform routine psychosocial risk assessment in pregnancy.

The experience of pregnancy and birth with midwives: results from the Canadian maternity experiences survey.

BACKGROUND: In Canada maternity care is publicly funded, and although women may choose their care providers, choices may be limited. The purpose of this study was to compare perceptions of maternity outcomes and experiences of those who received care from midwives with those who received care from other providers. METHODS: Based on the 2006 Canadian census, a random sample of women (n = 6,421) who had recently given birth in Canada completed a computer-assisted telephone interview for the Maternity Experiences Survey. The sample was stratified according to province or territory where birth occurred, age, rural or urban residence, and presence of other children in the home. Those who were 15 years of age and older, gave birth to a singleton baby, and were living with their infant were eligible for inclusion. RESULTS: Women whose primary prenatal providers were midwives had fewer ultrasounds and were more likely to attend prenatal classes and have at least five or more prenatal visits. They were also more likely to rate satisfaction with their maternity experience as "very positive" and be satisfied with information provided on a variety of pregnancy and birth topics if their primary prenatal provider was a midwife. They were almost half as likely to experience induction and 7.33 times more likely to experience a medication-free delivery. They were more likely to initiate and maintain breastfeeding at 3 and 6 months. CONCLUSIONS: Evidence shows that midwifery outcomes and levels of satisfaction meet or exceed Canadian maternity care standards. Facilitation of the continuing integration of midwives as autonomous practitioners throughout Canada is recommended. (BIRTH 38:3 September 2011).

Breastfeeding policies and practices in Canadian hospitals: comparing 1993 with 2007.

BACKGROUND: The Baby-Friendly Hospital Initiative (BFHI) promotes the World Health Organization International Code of Marketing of Breast-milk Substitutes (WHO Code) and the WHO/UNICEF's Ten Steps to Successful Breastfeeding (Ten Steps). The purpose of this study is to describe and compare maternity hospitals' adherence to the BFHI in 1993 and 2007 for Canada and for each province and territory. METHODS: A survey of all Canadian maternity hospitals was conducted in 1993 and 2007 on routine maternity care practices and policies including infant feeding. RESULTS: The overall response rate was 91 percent (n = 523/572 hospitals) in 1993 and 92 percent (n = 323/353 hospitals) in 2007. Eighty-two percent (415/507) of hospitals in 1993 and 68 percent (198/292) in 2007 had exclusive contracts with formula companies. Fifty-eight percent (302/517) of hospitals in 1993 and 90 percent (289/322) in 2007 never gave breastfeeding mothers sample packs containing formula. Fifty-eight percent (296/507) in 1993 and 85 percent (273/321) in 2007 had written breastfeeding policies (Step 1); 97 percent (503/518) in 1993 and 99 percent (320/322) in 2007 allowed mothers to breastfeed, on cue, whenever the babies indicated an interest 24 hours a day (Step 8); 24 percent (126/519) in 1993 and 64 percent (206/321) in 2007 reported that they did not provide soothers (Step 9); 58 percent (297/513) in 1993 and 68 percent (215/316) in 2007 always offered information on breastfeeding support groups and/or advice at time of discharge (Step 10). CONCLUSIONS: In the 14 years separating the two surveys, Canadian maternity hospitals substantially improved their implementation of the WHO Code and their adherence to the WHO/UNICEF Ten Steps.

Use of routine interventions in labour and birth in Canadian hospitals: comparing results of the 1993 and 2007 Canadian hospital maternity policies and practices surveys.

OBJECTIVES: To compare policies and practices of routine interventions in labour and birth in Canadian hospitals in 1993 and 2007 and to describe trends regarding adherence to evidence-based guidelines. METHODS: We used data from surveys of Canadian hospitals in 1993 and 2007 on routine maternity care practices and policies, including interventions in labour and birth. RESULTS: The response rate of hospitals in 1993 was 91% (523/572), and in 2007 it was 92% (323/353). In 1993, 65% of hospitals (335/516) had a policy that all women should have initial electronic fetal heart rate monitoring, and in 2007, 74% (235/319) had such a policy. In 1993, 55% of hospitals (284/516) used epidural anaesthesia as one of the methods for pain control, and in 2007, 87% of hospitals (278/318) did so. In 1993, 37% of hospitals (193/521) had a "no enema/suppository" policy on admission, and in 2007, 88% (282/322) did. In 1993, 87% of hospitals (450/516) had a policy encouraging the presence of both the woman's partner and other labour support people in the room during the course of labour; in 2007, 80% (259/323) did. In 1993, hospitals estimated that 62% of primiparous women and 44% of multiparous women had an episiotomy in their units. In 2007, the episiotomy rate, irrespective of parity, was 17%. In 1993, 20% of hospitals (98/498) had a policy specifying the length of the second stage of labour, and in 2007, 33% (101/307) had such a policy. CONCLUSION: Positive and negative trends in adherence to best practices were seen in policies and practices of routine interventions during labour and birth in Canadian hospitals between 1993 and 2007.

Comparison of maternity experiences of Canadian-born and recent and non-recent immigrant women: findings from the Canadian Maternity Experiences Survey.

OBJECTIVE: To compare the maternity experiences of immigrant women (recent, ≤ 5 years in Canada; non-recent > 5 years) with those of Canadian-born women. METHODS: This study was based on data from the Canadian Maternity Experiences Survey of the Public Health Agency of Canada. A stratified random sample of 6421 women was drawn from a sampling frame based on the 2006 Canadian Census of Population. Weighted proportions were calculated using survey sample weights. Multivariable logistic regression was used to estimate odds ratios comparing recent immigrant women with Canadian-born women and non-recent immigrant women with Canadian-born women, adjusting for education, income, parity, and maternal age. RESULTS: The sample comprised 7.5% recent immigrants, 16.3% non-recent immigrants, and 76.2% Canadian-born women. Immigrant women reported experiencing less physical abuse and stress, and they were less likely to smoke or consume alcohol during pregnancy, than Canadian women; however, they were more likely to report high levels of postpartum depression symptoms and were less likely to have access to social support, to take folic acid before and during pregnancy, to rate their own and their infant's health as optimal, and to place their infants on their backs for sleeping. Recent and non-recent immigrant women also had different experiences, suggesting that duration of residence in Canada plays a role in immigrant women's maternity experiences. CONCLUSION: These findings can assist clinicians and policy-makers to understand the disparities that exist between immigrant and non-immigrant women in order to address the needs of immigrant women more effectively.

Giving birth in two maternity hospitals in Lithuania.

BACKGROUND: In many hospitals in former Soviet countries, traditional Soviet perinatal policies remain in place, although in others reforms have been introduced. This study explores women's experiences during labor and birth in two Lithuanian maternity hospitals. The hospitals differed in that one (S) followed traditional Soviet era maternity practices whereas the other (P) had been exposed to World Health Organization-Euro practices and policies with respect to more up-to-date evidence-based and family-centered care. METHODS: Consecutive women giving birth in the two maternity hospitals were asked to participate in a survey. Completed responses were obtained from 416 women in one hospital (P) and 304 in the other hospital (S) representing 92.4 and 67.5 percent response rates, respectively. RESULTS: Rates of interventions in both hospitals were similarly high with, however, P hospital being more likely to be sensitive to women's psychosocial needs, such as being allowed to eat and drink more often during labor, and to have their husband or partner with them for labor and birth. CONCLUSION: It appears that in Lithuania, as in many parts of the world, introducing changes to the clinical care of birth takes time, and psychosocial changes may be easier to introduce than alterations in clinical practice.

Cesarean and vaginal birth in canadian women: a comparison of experiences.

BACKGROUND: Many publications have examined the reasons behind the rising cesarean delivery rate around the world. Women's responses to the Maternity Experiences Survey of the Canadian Perinatal Surveillance System were examined to explore correlates of having a cesarean section on other experiences surrounding labor, birth, mother-infant contact, and breastfeeding. METHODS: A randomly selected sample of 8,244 estimated eligible women stratified primarily by province and territory was drawn from the May 2006 Canadian Census. Completed responses were obtained from 6,421 women (78%). RESULTS: Three-quarters of the women (73.7%) gave birth vaginally and 26.3 percent by cesarean section, including 13.5 percent with a planned cesarean and 12.8 percent with an unplanned cesarean. In addition to more interventions in labor, women who had a cesarean birth after attempting a vaginal birth had less mother-infant contact after birth and less optimal breastfeeding practices. CONCLUSION: Findings from the Maternity Experiences Survey indicated that women who have cesarean births experience more interventions during labor and birth and have less optimal birthing and early parenting outcomes.

A randomized breast-feeding promotion intervention did not reduce child obesity in Belarus.

The evidence that breast-feeding protects against obesity is based on observational studies, with potential for confounding and selection bias. This article summarizes a previously published study in which we assessed whether an intervention designed to promote exclusive and prolonged breast-feeding affects children's height, weight, adiposity, and blood pressure (BP) at age 6.5 y. The Promotion of Breastfeeding Intervention Trial (PROBIT) is a cluster-randomized trial of a breast-feeding promotion intervention based on the WHO/UNICEF Baby-Friendly Hospital Initiative. A total of 17,046 healthy breast-fed infants were enrolled from 31 Belarussian maternity hospitals and affiliated clinics, of whom 13,889 (81.5%) were followed up at 6.5 y with duplicate measurements of height, weight, waist circumference, triceps and subscapular skinfold thicknesses, systolic and diastolic BP. Analysis was based on intention to treat, with statistical adjustment for clustering within hospitals/clinics to permit inferences at the individual level. The experimental intervention led to a large increase in exclusive breast-feeding at 3 mo (43.3% vs. 6.4%, P < 0.001) and a significantly higher prevalence of any breast-feeding throughout infancy. No significant intervention effects were observed on height, BMI, adiposity measures, or BP. The breast-feeding promotion intervention resulted in substantial increases in the duration and exclusivity of breast-feeding yet did not reduce measures of adiposity at age 6.5 y. Previous reports of protective effects against obesity may reflect uncontrolled bias caused by confounding and selection.

Breastfeeding rates and hospital breastfeeding practices in Canada: a national survey of women.

BACKGROUND: The Baby-Friendly Hospital Initiative was launched by the World Health Organization and UNICEF in 1989 to promote, protect, and support breastfeeding worldwide. The objective of this study was to report breastfeeding rates and adherence to the Baby Friendly Hospital Initiative of the World Health Organization and UNICEF in Canada, as reported by participants in the Maternity Experiences Survey of the Canadian Perinatal Surveillance System. METHODS: Eligible women (n = 8,244) were identified from a randomly selected sample of infants born 3 months before the May 2006 Canadian Census, and stratified by province or territory. Birth mothers living with their infants at the time of interview were invited to participate in a computer-assisted telephone interview conducted by Statistics Canada on behalf of the Public Health Agency of Canada. Interviews took approximately 45 minutes and were completed when infants were between 5 and 10 months old (between 9 and 14 months in the territories). Completed responses were obtained from 6,421 women (78% response rate). Nineteen of 309 questions concerned early mother-infant contact and breastfeeding practices. RESULTS: Breastfeeding intention (90.0%) and initiation (90.3%) rates were high, although exclusive breastfeeding rates at 6 months after birth (14.4%) were lower than desirable. The findings suggested a low adherence to several best practices advocated by the Baby-Friendly Hospital Initiative. CONCLUSION: Although breastfeeding initiation rates were relatively high in Canada, exclusive breastfeeding duration fell short of globally recommended standards.