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.

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.

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.

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.

Prenatal exposure to endocrine disrupting chemical mixtures and infant birth weight: A Bayesian analysis using kernel machine regression.

BACKGROUND: Pregnant women are regularly exposed to a multitude of endocrine disrupting chemicals (EDCs). EDC exposures, both individually and as mixtures, may affect fetal growth. The relationship of EDC mixtures with infant birth weight, however, remains poorly understood. We examined the relations between prenatal exposure to EDC mixtures and infant birth weight. METHODS: We used data from the Maternal-Infant Research on Environmental Chemicals (MIREC) Study, a pan-Canadian cohort of 1857 pregnant women enrolled between 2008 and 2011. We quantified twenty-one chemical concentrations from five EDC classes, including organochlorine compounds (OCs), metals, perfluoroalkyl substances (PFAS), phenols and phthalate metabolites that were detected in >70% of urine or blood samples collected during the first trimester. In our primary analysis, we used Bayesian kernel machine regression (BKMR) models to assess variable importance, explore EDC mixture effects, and identify any interactions among EDCs. Our secondary analysis used traditional linear regression to compare the results with those of BKMR and to quantify the changes in mean birth weight in relation to prenatal EDC exposures. RESULTS: We found evidence that mixtures of OCs and metals were associated with monotonic decreases in mean birth weight across the whole range of exposure. trans-Nonachlor from the OC mixture and lead (Pb) from the metal mixture had the greatest impact on birth weight. Our linear regression analysis corroborated the BKMR results and found that a 2-fold increase in trans-nonachlor and Pb concentrations reduced mean birth weight by -38 g (95% confidence interval (CI): -67, -10) and -39 g (95% CI: -69, -9), respectively. A sex-specific association for OC mixture was observed among female infants. PFAS, phenols and phthalates were not associated with birth weight. No interactions were observed among the EDCs. CONCLUSIONS: Using BKMR, we observed that both OC and metal mixtures were associated with decreased birth weight in the MIREC Study. trans-Nonachlor from the OC mixture and Pb from the metal mixture contributed most to the adverse effects.

Perinatal outcomes of planned home birth after cesarean and planned hospital vaginal birth after cesarean at term gestation in British Columbia, Canada: A retrospective population-based cohort study.

BACKGROUND: The aim of this retrospective population-based cohort study was to determine whether the mode of delivery and maternal and neonatal outcomes differ between planned home VBAC (HBAC) and planned hospital VBAC. METHODS: All midwifery clients with at least one prior cesarean birth delivered between April 2000 and March 2017 (N = 4741; n = 4180 planned hospital VBAC, n = 561 planned HBAC) were included. Multivariate binomial logistic regression analyses were conducted to calculate the odds ratios adjusted for the potential covariates. The primary outcome was the mode of delivery, and the secondary outcomes were uterine rupture/dehiscence, postpartum hemorrhage, nonintact perineum, episiotomy, obstetric trauma, Apgar score <7 at 5 minutes, neonatal resuscitation requiring positive pressure ventilation, neonatal intensive care unit admission, and a composite outcome of severe neonatal mortality and morbidity and maternal mortality and morbidity. RESULTS: Planned HBAC was associated with a significant 39% decrease in the odds of having a cesarean birth (aOR 0.61, 95% CI 0.47-0.79) adjusting for the prepregnancy and pregnancy characteristics. Severe adverse outcomes were relatively rare in both settings; thus, our study did not have sufficient power to detect the true differences associated with the place of birth. CONCLUSIONS: Home births for those eligible for VBACs and attended by registered midwives within an integrated health system were associated with higher vaginal birth rates compared with planned hospital VBACs. Severe adverse outcomes were relatively rare in both settings.

Maternal Vitamin D Levels During Pregnancy and Their Effects on Maternal-Fetal Outcomes: A Systematic Review.

To synthesize and critically review the current evidence available on maternal vitamin D deficiency and its effects on maternal-fetal outcomes, this study reviewed the maternal-fetal outcomes, including prolonged labour or cesarean delivery, preeclampsia, gestational diabetes, low birth weight and small for gestational age, and preterm birth. An extensive systematic searched was performed in Medline and EMBASE, where a medical subject heading (MeSH) was used with terms "Vitamin D/25(OH)D" and "pregnancy/fetal outcomes"; these terms were combined with "and." In Web of Science and Google Scholar, a key word search was used. Nineteen articles were included for full review. This review found that the current state of the evidence is equivocal for maternal-fetal outcomes such as the risk of prolonged labour and cesarean delivery, gestational diabetes, low birth weight and small for gestational age, and preterm birth. Although some previous studies have found improvement in pregnancy outcomes with sufficient vitamin D levels, others have not shown any association with the aforementioned outcomes. This systematic review also highlights an association between the risk of preeclampsia and maternal vitamin D levels that is found to be consistent among studies.

2009 IOM guidelines for gestational weight gain: how well do they predict outcomes across ethnic groups?

Objective: To determine whether the Institute Of Medicine's (IOM) 2009 guidelines for weight-gain during pregnancy are predictive of maternal and infant outcomes in ethnic minority populations.Methods: We designed a population-based study using administrative data on 181,948 women who delivered live singleton births in Washington State between 2006-2008. We examined risks of gestational hypertension, preeclampsia/eclampsia, cesarean delivery, and extended hospital stay in White, Black, Native-American, East-Asian, Hispanic, South-Asian and Hawaiian/Pacific islander women according to whether they gained more or less weight during pregnancy than recommended by IOM guidelines. We also examined risks of neonatal outcomes including Apgar score <7 at 5 min, admission to NICU, requirement for ventilation, and a diagnosis of small or large for gestational age at birth.Results: Gaining too much weight was associated with increased odds for gestational hypertension (adjusted OR (aOR) ranged between 1.53-2.22), preeclampsia/eclampsia (aOR 1.44-1.81), cesarean delivery (aOR 1.07-1.38) and extended hospital stay (aOR 1.06-1.28) in all ethnic groups. Gaining too little weight was associated with decreased odds for gestational hypertension and delivery by cesarean section in Whites, Blacks and Hispanics. Gaining less weight or more weight than recommended was associated with increased odds for small for gestational age and large for gestational age infants respectively, in all ethnic groups.Conclusions: Adherence to the 2009 IOM guidelines for weight gain during pregnancy reduces risk for various adverse maternal outcomes in all ethnic groups studied. However, the guidelines were less predictive of infant outcomes with the exception of small and large for gestational age.Abbreviations: GWG: Gestational weight gain; IOM/NRC; Institute of Medicine and National Research Council; NICU: Neonatal intensive care need for ventilation; SGA: Small for gestational age; LGA: Large for gestational age; BERD: Birth Events Records Database; CHARS: Comprehensive Hospital Discharge Abstract Reporting System; ICD: International Classification of Disease; LMP: Last menstrual period; OR: Odds ratio.

Coal smoke, gestational cadmium exposure, and fetal growth.

BACKGROUND: Gestational cadmium exposure may impair fetal growth. Coal smoke has largely been unexplored as a source of cadmium exposure. We investigated the relationship between gestational cadmium exposure and fetal growth, and assessed coal smoke as a potential source of airborne cadmium, among non-smoking pregnant women in Ulaanbaatar, Mongolia, where coal combustion in home heating stoves is a major source of outdoor and indoor air pollution. METHODS: This observational study was nested within the Ulaanbaatar Gestation and Air Pollution Research (UGAAR) study, a randomized controlled trial of portable high efficiency particulate air (HEPA) filter air cleaner use during pregnancy, fetal growth, and early childhood development. We measured third trimester blood cadmium concentrations in 374 out of 465 participants who had a live birth. We used multiple linear and logistic regression to assess the relationships between log2-transformed maternal blood cadmium concentrations and birth weight, length, head circumference, ponderal index, low birth weight, small for gestational age, and preterm birth in crude and adjusted models. We also evaluated the relationships between log2-transformed blood cadmium concentrations and the density of coal-burning stoves within 5000 m of each participant's apartment as a proxy of coal smoke emissions from home heating stoves. RESULTS: The median (25th,75th percentile) blood cadmium concentration was 0.20 (0.15, 0.29) µg/L. A doubling of blood cadmium was associated with a 95 g (95% CI: 34, 155 g) reduction in birth weight in adjusted models. An interquartile range increase in coal stove density (from 3.4 to 4.9 gers/hectare) surrounding participants' apartments was associated with a 12.2% (95% CI: 0.3, 25.6%) increase in blood cadmium concentrations. CONCLUSIONS: Gestational cadmium exposure was associated with reduced birth weight. In settings where coal is a widely used fuel, cadmium may play a role in the putative association between air pollution and impaired fetal growth.

Maternal unwanted and intrusive thoughts of infant-related harm, obsessive-compulsive disorder and depression in the perinatal period: study protocol.

BACKGROUND: Unwanted, intrusive thoughts of harm-related to the infant are reported by the vast majority of new mothers, with half of all new mothers reporting unwanted, intrusive thoughts of harming their infant on purpose. Thoughts of intentional harm, in particular, are distressing to women, their partners and the people who care for them. While maternal, unwanted and intrusive thoughts of infant-related harm are known to be associated with obsessive compulsive disorder (OCD) and depression, preliminary evidence suggests that they are not associated with an increased risk of harm to infants. Perinatal care providers and policy makers, as well as new mothers and their partners require evidence-based information in order to respond appropriately to these types of thoughts. The purpose of this research is to address important gaps regarding the (a) prevalence and characteristics of intrusive, unwanted thoughts of baby-related harm, (b) their association (or lack thereof) with child abuse, and (c) the prevalence and course of obsessive-compulsive disorder and depression in the perinatal period. METHODS: Participant were 763 English-speaking women and recruited during pregnancy. In this province-wide study in British Columbia, participants were recruited proportionally from hospitals, city centers and rural communities between January 23, 2014 and September 09, 2016. Participants were administered online questionnaires and diagnostic interviews over the phone at 33-weeks gestation, 7-weeks postpartum and 4-months postpartum. The study assessed intrusive and unwanted thoughts of harm related to the infant, obsessive-compulsive disorder (OCD) and major depressive episode (MDE) disorders and symptomatology, sleep, medical outcomes, parenting attitudes, and infant abuse. DISCUSSION: There is a scarcity of literature concerning maternal unwanted, intrusive, postpartum thoughts of infant-related harm and their relationship to child harming behaviors, OCD and depression. This longitudinal cohort study was designed to build on the existing research base to ensure that policy developers, child protection workers and health-care providers have the guidance they need to respond appropriately to the disclosure of infant-related harm thoughts. Thus, its main goals will be to investigate whether intrusive postpartum thoughts of infant-related harm are a risk factor for child abuse or the development of OCD.

Improving birth outcomes for women who are substance using or have mental illness: a Canadian cohort study comparing antenatal midwifery and physician models of care for women of low socioeconomic position.

BACKGROUND: Some observational studies have shown improved birth outcomes for women of low socioeconomic position (SEP) receiving antenatal midwifery versus physician care. To understand for whom and under what circumstances midwifery care is associated with better birth outcomes we examined whether psychosocial risk including substance use, mental illness, social assistance, residence in a neighbourhood of low/moderate SEP, and teen maternal age modified the association between model of care (midwifery versus physician) and small-for-gestational-age (SGA) or preterm birth (PTB) for women of low SEP. METHODS: For this retrospective cohort study, maternity data from the British Columbia Perinatal Data Registry were linked with Medical Services Plan billing data. We report adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for SGA birth (< the 10th percentile) and PTB (< 37 weeks' completed gestation). For tests of interaction between antenatal models of care and psychosocial risk, p-values < 0.10 were considered statistically significant. Women were eligible for inclusion if they were residents of British Columbia, Canada, carried a singleton fetus, had low to moderate medical/obstetric risk, birthed between April 1, 2008 and Dec. 31, 2012, and received a health insurance subsidy (n = 33,937). RESULTS: Midwifery versus obstetrician patients had lower odds of PTB. The difference was 31% larger among substance users (aOR 0.24, 95% CI: 0.11-0.54) compared to non-substance users (aOR 0.55, 95% CI: 0.45-0.68). Additionally, there was a 34% statistically significant absolute difference in odds of PTB for midwifery versus obstetrician patients with both mental illness and substance use (aOR 0.18, 95% CI: 0.06-0.55) compared to women with neither mental illness nor substance use (aOR 0.52, 95% CI: 0.41-.66). Results demonstrated a consistent association between midwifery versus physician care and lower odds of SGA, yet effects were not statistically significantly different for women with higher or lower psychosocial risk. CONCLUSION: Among low SEP women in British Columbia, Canada, antenatal midwifery compared to obstetrician care was associated with reduced odds of PTB. Odds were lower among women with substance use, and mental illness and substance use, than among women without these risk factors.

A systematic review of nonpharmacological prenatal interventions for pregnancy-specific anxiety and fear of childbirth.

BACKGROUND: Despite a sharp increase in the number of publications that report on treatment options for pregnancy-specific anxiety and fear of childbirth (PSA/FoB), no systematic review of nonpharmacological prenatal interventions for PSA/FoB has been published. Our team addressed this gap, as an important first step in developing guidelines and recommendations for the treatment of women with PSA/FoB. METHODS: Two databases (PubMed and Mendeley) were searched, using a combination of 42 search terms. After removing duplicates, two authors independently assessed 208 abstracts. Sixteen studies met eligibility criteria, ie, the article reported on an intervention, educational component, or treatment regime for PSA/FoB during pregnancy, and included a control group. Independent quality assessments resulted in the retention of seven studies. RESULTS: Six of seven included studies were randomized controlled trials (RCTs) and one a quasi-experimental study. Five studies received moderate quality ratings and two strong ratings. Five of seven studies reported significant changes in PSA/FoB, as a result of the intervention. Short individual psychotherapeutic interventions (1.5-5 hours) delivered by midwives or obstetricians were effective for women with elevated childbirth fear. Interventions that were effective for pregnant women with a range of different fear/anxiety levels were childbirth education at the hospital (2 hours), prenatal Hatha yoga (8 weeks), and an 8-week prenatal education course (16 hours). CONCLUSIONS: Findings from this review can inform the development of treatment approaches to support pregnant women with PSA/FoB.

Unknown Antenatal HIV-Infection Status Has Declined Over Time in British Columbia, Canada.

OBJECTIVES: The objective was to determine whether the proportion of pregnant women with unknown antenatal HIV-infection status is declining over time in British Columbia (BC) and whether associated factors are amenable to intervention. METHODS: Through a retrospective cohort study of all deliveries in the British Columbia Perinatal Data Registry from 2005 to 2011, we examined the association between year of delivery and no recorded antenatal HIV test result. The trend in unknown antenatal HIV-infection status over time was evaluated by the Cochran-Mantel-Haenzsel test and multivariable logistic regression was used to determine the odds of unknown antenatal HIV-infection status by year of delivery. RESULTS: A total of 299 771 deliveries were included; 9.1% had unknown antenatal HIV-infection status with a declining trend from 12.7% to 5.5% from 2005 to 2011 (P <0.0001). Adjusted for maternal age, parity, gestation, and number of antenatal visits, pregnant women were 64% less likely to not have antenatal HIV testing in 2011 compared to 2005 (adjusted odds ratio [aOR] 0.36; 95% CI 0.34-0.38). The odds of no antenatal HIV testing were 54% higher in multiparous compared to primiparous women (aOR 1.54; 95% CI 1.49-1.58), and each additional antenatal visit reduced the odds of no antenatal HIV testing by 8% (aOR 0.92; 95% CI 0.92-0.93). CONCLUSION: The declining trend in unknown antenatal HIV-infection status in BC is encouraging. Consistent with Canadian and BC HIV testing guidelines, further strengthening of routine testing at the first antenatal visit in all pregnancies irrespective of previous HIV testing, particularly in multiparous women, could achieve universal pregnancy HIV testing in BC.

Evaluation of an Information Pamphlet for Women Considering Epidural Analgesia in Labour.

OBJECTIVE: This study sought to assess change in knowledge and preference for epidural use associated with use of an information pamphlet and to explore women's decision-making and information needs regarding pain relief in labour. METHODS: Six focus groups with women who were pregnant or had given birth during the past 12 months were conducted in three northern communities in British Columbia. Following completion of a 10-item knowledge pretest, women were randomly assigned to read either a short version or a detailed version of the pamphlet and then complete a post-test. After reading the alternate pamphlet they participated in a moderated discussion. Pretest and post-test knowledge scores were compared, and a thematic analysis of focus group data was conducted. RESULTS: Knowledge scores increased (2.12 points out of a possible total of 10; standard deviation 2.38; 95% CI 1.38 to 2.87). There was no difference in knowledge change or epidural preferences according to which version participants read first. Women preferred the detailed version and indicated that its information was more balanced. Four themes related to decision-making and information needs arose from the focus groups: making an informed choice, being open-minded, wanting comprehensive information, and experiencing pressure to have/not have an epidural. CONCLUSION: An illustrated information pamphlet can significantly increase women's knowledge of benefits and risks of epidural analgesia, but it is not associated with change of preference. Women prefer to receive comprehensive information prenatally to support informed choices in labour.

Do Women Have a Choice? Care Providers' and Decision Makers' Perspectives on Barriers to Access of Health Services for Birth after a Previous Cesarean.

BACKGROUND: Repeat cesarean delivery is the single largest contributor to the escalating cesarean rate worldwide. Approximately 80 percent of women with a past cesarean are candidates for vaginal birth after a cesarean (VBAC), but in Canada less than one-third plan VBAC. Emerging evidence suggests that these trends may be due in part to nonclinical factors, including care provider practice patterns and delays in access to surgical and anesthesia services. This study sought to explore maternity care providers' and decision makers' attitudes toward and experiences with providing and planning services for women with a previous cesarean. METHODS: In-depth, semi-structured interviews were conducted with family physicians, midwives, obstetricians, nurses, anesthetists, and health service decision makers recruited from three rural and two urban Canadian communities. Constructivist grounded theory informed iterative data collection and analysis. RESULTS: Analysis of interviews (n = 35) revealed that the factors influencing decisions resulted from interactions between the clinical, organizational, and policy levels of the health care system. Physicians acted as information providers of clinical risks and benefits, with limited discussion of patient preferences. Decision makers serving large hospitals revealed concerns related to liability and patient safety. These stemmed from competing access to surgical resources. CONCLUSIONS: To facilitate women's increased access to planned VBAC, it is necessary to address the barriers perceived by care providers and decision makers. Strategies to mitigate concerns include initiating decision support immediately after the primary cesarean, addressing the social risks that influence women's preferences, and managing perceptions of patient and litigation risks through shared decision making.

A Predictive Model for Cesarean Among Low-Risk Nulliparous Women in Spontaneous Labor at Hospital Admission.

BACKGROUND: To determine if maternal characteristics measurable upon admission to hospital predict cesarean among low-risk spontaneously laboring nulliparous women. METHODS: We undertook a secondary analysis of data from a clinical trial of early labor support for nulliparous women carrying a singleton fetus in cephalic presentation at 37-41 weeks of gestation in British Columbia, Canada. Study participants did not have any discernible risk factors for cesarean at the onset of labor. We developed a prediction model using logistic regression from a sample of 1,302 participants. Internal validation of the model was accomplished by 10-fold cross validation, after which probability scores were calculated based on the mean logistic regression model. To determine the accuracy of our predictive model, we calculated the specificity and sensitivity and the area under the receiver operating curve. RESULTS: Advanced maternal age, shorter maternal height, greater gestational age, perception of labor lasting more than 24 hours, and mild or moderate contractions, less cervical dilation, and higher fetal station at time of hospital admission independently predicted cesarean. The C-statistic for the predictive model was 0.71 (0.64-0.75) and the sensitivity and specificity of the model were 0.80 (95% CI 0.76-0.84) and 0.48 (95% CI 0.44-0.52), respectively. CONCLUSIONS: Among nulliparous women without apparent risk for cesarean at the time of hospital admission, cesarean delivery can be predicted with 70 percent accuracy using routinely collected information. Tailoring intrapartum care to promote vaginal birth according to a prediction model for cesarean risk deserves further study among apparently low risk women.

Lifetime substance use as a predictor of postpartum mental health.

Postpartum mood disorders (PPMD) affect approximately 10-20% of women and have adverse consequences for both mom and baby. Lifetime substance use has received limited attention in relation to PPMD. The present study examined associations of lifetime alcohol and drug use with postpartum mental health problems. Women (n = 100) within approximately 3 months postpartum (M = 2.01, SD = 1.32) participated in semi-structured interviews querying lifetime substance use, mental health history, and postpartum symptoms of anxiety, stress, posttraumatic stress disorder (PTSD), depression, and obsessive compulsive disorder. The study was conducted in an urban Canadian city from 2009 to 2010. Analyses revealed that lifetime substance use increased the variability explained in postpartum PTSD (p = .011), above and beyond sociodemographic characteristics and mental health history. The same trend, though not significant, was observed for stress (p = .059) and anxiety (p = .070). Lifetime drug use, specifically, was associated with postpartum stress (p = .021) and anxiety (p = .041), whereas lifetime alcohol use was not (ps ≥ .128). Findings suggest that lifetime drug use is associated with PPMD. Future research should examine whether screening for lifetime drug use during antenatal and postpartum care improves identification of women experiencing PPMD.

The prevalence and incidence of perinatal anxiety disorders among women experiencing a medically complicated pregnancy.

Over 20% of pregnancies involve medical difficulties that pose some threat to the health and well-being of the mother, her developing infant, or both. We report on the first comparison of the prevalence and incidence of maternal anxiety disorders (AD) in pregnancy and the postpartum, across levels of medical risk in pregnancy. Pregnant women (N = 310) completed postnatal screening measures for anxiety. Women who scored at or above cutoff on one or more of the screening measures were administered a diagnostic interview (n = 115) for AD. Pregnancies were classified into low, moderate, or high risk based on self-report and contact with high-risk maternity clinics. The incidence of AD in pregnancy was higher among women classified as experiencing a medically moderate or high-risk pregnancy, compared with women classified as experiencing a medically low-risk pregnancy. Across risk groups, there were no differences in AD prevalence or in the incidence of AD in the postpartum. Demographic characteristics and parity did not contribute meaningfully to outcomes. Pregnancies characterized by medical risks are associated with an increased likelihood of new onset AD. Women experiencing medically complex pregnancies should be screened for anxiety and offered appropriate treatment.