Inequities in utilization of prenatal care: a population-based study in the Canadian province of Manitoba.

BACKGROUND: Ensuring high quality and equitable maternity services is important to promote positive pregnancy outcomes. Despite a universal health care system, previous research shows neighborhood-level inequities in utilization of prenatal care in Manitoba, Canada. The purpose of this population-based retrospective cohort study was to describe prenatal care utilization among women giving birth in Manitoba, and to determine individual-level factors associated with inadequate prenatal care. METHODS: We studied women giving birth in Manitoba from 2004/05-2008/09 using data from a repository of de-identified administrative databases at the Manitoba Centre for Health Policy. The proportion of women receiving inadequate prenatal care was calculated using a utilization index. Multivariable logistic regressions were used to identify factors associated with inadequate prenatal care for the population, and for a subset with more detailed risk information. RESULTS: Overall, 11.5% of women in Manitoba received inadequate, 51.0% intermediate, 33.3% adequate, and 4.1% intensive prenatal care (N = 68,132). Factors associated with inadequate prenatal care in the population-based model (N = 64,166) included northern or rural residence, young maternal age (at current and first birth), lone parent, parity 4 or more, short inter-pregnancy interval, receiving income assistance, and living in a low-income neighborhood. Medical conditions such as multiple birth, hypertensive disorders, antepartum hemorrhage, diabetes, and prenatal psychological distress were associated with lower odds of inadequate prenatal care. In the subset model (N = 55,048), the previous factors remained significant, with additional factors being maternal education less than high school, social isolation, and prenatal smoking, alcohol, and/or illicit drug use. CONCLUSION: The rate of inadequate prenatal care in Manitoba ranged from 10.5-12.5%, and increased significantly over the study period. Factors associated with inadequate prenatal care included geographic, demographic, socioeconomic, and pregnancy-related factors. Rates of inadequate prenatal care varied across geographic regions, indicating persistent inequities in use of prenatal care. Inadequate prenatal care was associated with several individual indicators of social disadvantage, such as low income, education less than high school, and social isolation. These findings can inform policy makers and program planners about regions and populations most at-risk for inadequate prenatal care and assist with development of initiatives to reduce inequities in utilization of prenatal care.

Unconditional Prenatal Income Supplement and Birth Outcomes.

BACKGROUND AND OBJECTIVES: Perinatal outcomes have improved in developed countries but remain poor for disadvantaged populations. We examined whether an unconditional income supplement to low-income pregnant women was associated with improved birth outcomes. METHODS: This study included all mother-newborn pairs (2003-2010) in Manitoba, Canada, where the mother received prenatal social assistance, the infant was born in the hospital, and the pair had a risk screen (N = 14 591). Low-income women who received the income supplement (Healthy Baby Prenatal Benefit [HBPB], n = 10 738) were compared with low-income women who did not receive HBPB (n = 3853) on the following factors: low birth weight, preterm, small and large for gestational age, Apgar score, breastfeeding initiation, neonatal readmission, and newborn hospital length of stay (LOS). Covariates from risk screens were used to develop propensity scores and to balance differences between groups in regression models; γ sensitivity analyses were conducted to assess sensitivity to unmeasured confounding. Population-attributable and preventable fractions were calculated. RESULTS: HBPB was associated with reductions in low birth weight (aRR, 0.71 [95% CI, 0.63-0.81]), preterm births (aRR, 0.76 [95% CI, 0.69-0.84]) and small for gestational age births (aRR, 0.90 [95% CI, 0.81-0.99]) and increases in breastfeeding (aRR, 1.06 [95% CI, 1.03-1.09]) and large for gestational age births (aRR, 1.13 [95% CI, 1.05-1.23]). For vaginal births, HBPB was associated with shortened LOS (weighted mean, 2.86; P < .0001). Results for breastfeeding, low birth weight, preterm birth, and LOS were robust to unmeasured confounding. Reductions of 21% (95% CI, 13.6-28.3) for low birth weight births and 17.5% (95% CI, 11.2-23.8) for preterm births were associated with HBPB. CONCLUSIONS: Receipt of an unconditional prenatal income supplement was associated with positive outcomes. Placing conditions on income supplements may not be necessary to promote prenatal and perinatal health.

Have we left some behind? Trends in socio-economic inequalities in breastfeeding initiation: a population-based epidemiological surveillance study.

OBJECTIVES: Breastfeeding is associated with improved health. Surveillance data show that breastfeeding initiation rates have increased; however, limited work has examined trends in socio-economic inequalities in initiation. The study's research question was whether socio-economic inequalities in breastfeeding initiation have changed over the past 20 years. METHODS: This population-based study is a project within PATHS Equity for Children. Analyses used hospital discharge data for Manitoba mother-infant dyads with live births, 1988-2011 (n=316,027). Income quintiles were created, each with ~20% of dyads. Three-year, overall and by-quintile breastfeeding initiation rates were estimated for Manitoba and two hospitals. Age-adjusted rates were estimated for Manitoba. Rates were modelled using generalized linear models. Three measures, rate ratios (RRs), rate differences (RDs) and concentration indices, assessed inequality at each time point. We also compared concentration indices with Gini coefficients to assess breastfeeding inequality vis-à-vis income inequality. Trend analyses tested for changes over time. RESULTS: Manitoba and Hospital A initiation rates increased; Hospital B rates did not change. Significant inequalities existed in nearly every period, across all three measures: RRs, RDs and concentration indices. RRs and concentration indices suggested little to no change in inequality from 1988 to 2011. RDs for Manitoba (comparing initiation in the highest to lowest income quintiles) did not change significantly over time. RDs decreased for Hospital A, suggesting decreasing socio-economic inequalities in breastfeeding; RDs increased for Hospital B. Income inequality increased significantly in Manitoba during the study period. CONCLUSIONS: Overall breastfeeding initiation rates can improve while inequality persists or worsens.

The effect of neighborhood socioeconomic status on education and health outcomes for children living in social housing.

OBJECTIVES: We explored differences in health and education outcomes between children living in social housing and not, and effects of social housing's neighborhood socioeconomic status. METHODS: In this cohort study, we used the population-based repository of administrative data at the Manitoba Centre for Health Policy. We included children aged 0 to 19 years in Winnipeg, Manitoba, in fiscal years 2006-2007 to 2008-2009 (n = 13,238 social housing; n = 174,017 others). We examined 5 outcomes: age-2 complete immunization, a school-readiness measure, adolescent pregnancy (ages 15-19 years), grade-9 completion, and high-school completion. Logistic regression and generalized estimating equation modeling generated rates. We derived neighborhood income quintiles (Q1 lowest, Q5 highest) from average household income census data. RESULTS: Children in social housing fared worse than comparative children within each neighborhood income quintile. When we compared children in social housing by quintile, preschool indicators (immunization and school readiness) were similar, but adolescent outcomes (grade-9 and high-school completion, adolescent pregnancy) were better in Q3 to Q5. CONCLUSIONS: Children in social housing had poorer health and education outcomes than all others, but living in social housing in wealthier areas was associated with better adolescent outcomes.

Data resource profile: Pathways to Health and Social Equity for Children (PATHS Equity for Children).

The PATHS Data Resource is a unique database comprising data that follow individuals from the prenatal period to adulthood. The PATHS Resource was developed for conducting longitudinal epidemiological research into child health and health equity. It contains individual-level data on health, socioeconomic status, social services and education. Individuals' data are linkable across these domains, allowing researchers to follow children through childhood and across a variety of sectors. PATHS includes nearly all individuals that were born between 1984 and 2012 and registered with Manitoba's universal health insurance programme at some point during childhood. All PATHS data are anonymized. Key concepts, definitions and algorithms necessary to work with the PATHS Resource are freely accessible online and an interactive forum is available to new researchers working with these data. The PATHS Resource is one of the richest and most complete databases assembled for conducting longitudinal epidemiological research, incorporating many variables that address the social determinants of health and health equity. Interested researchers are encouraged to contact [mchp_access@cpe.umanitoba.ca] to obtain access to PATHS to use in their own programmes of research.

Parents bereaved by offspring suicide: a population-based longitudinal case-control study.

CONTEXT Suicide bereavement remains understudied and poorly understood. OBJECTIVES To examine outcomes of parents bereaved by the suicide death of their offspring and to compare these with both nonbereaved parent controls and parents who had offspring die in a motor vehicle crash (MVC). DESIGN Population-based case-control study. Suicide-bereaved parents were compared with nonbereaved matched control parents in the general population (n = 1415) and with MVC-bereaved parents (n = 1132) on the rates of physician-diagnosed mental and physical disorders, social factors, and treatment use in the 2 years after death of the offspring. Adjusted relative rates (ARRs) were generated by generalized estimating equation models and adjusted for confounding factors. SETTING Manitoba, Canada. PARTICIPANTS All identifiable parents who had an offspring die by suicide between 1996 and 2007 (n = 1415). MAIN OUTCOME MEASURES Mental and physical disorders, social factors, and treatment use. RESULTS Suicide bereavement was associated with an increased rate of depression (ARR, 2.14; 95% CI, 1.88-2.43), anxiety disorders (ARR, 1.41; 95% CI, 1.24-1.60), and marital breakup (ARR, 1.18; 95% CI, 1.13-1.23) in the 2 years after the suicide of an offspring, as compared with the 2 years prior to the death. Suicide-bereaved and MVC-bereaved parents had very few differences on predeath to postdeath outcomes. Depression rate increases were greater for MVC-bereaved parents (19.9%) compared with suicide-bereaved parents (15.9%; P = .005), whereas suicide-bereaved parents had higher rate increases of hospitalization for mental illness (P = .049). Suicide-bereaved parents were more likely than their MVC-bereaved counterparts to have depression (ARR, 1.30; 95% CI, 1.06-1.61), physical disorders (ARR, 1.32; 95% CI, 1.19-1.45), and low income (ARR, 1.34; 95% CI, 1.18-1.51) before their offspring's death. CONCLUSIONS Suicide bereavement is associated with adverse mental health and social outcomes. These consequences appear similar to those associated with MVC bereavement. Parents who lose offspring to suicide appear to be a vulnerable group even prior to their offspring's death.

The right kind of evidence--integrating, measuring, and making it count in health equity research.

As health equity researchers, we need to produce research that is useful, policy-relevant, able to be understood and applied, and uses integrated knowledge translation (KT) approaches. The Manitoba Centre for Health Policy and its history of working with provincial government as well as regional health authorities is used as a case study of integrated KT. Whether or not health equity research "takes the day" around the decision-making table may be out of our realm, but as scientists, we need to ensure that it is around the table, and that it is understood and told in a narrative way. However, our conventional research metrics can sometimes get in the way of practicality and clear understanding. The use of relative rates, relative risks, or odds ratios can actually be detrimental to furthering political action. In the policy realm, showing the rates by socioeconomic group and trends in those rates, as well as incorporating information on absolute differences, may be better understood intuitively when discussing inequity. Health equity research matters, and it particularly matters to policy-makers and planners at the top levels of decision-making. We need to ensure that our messages are based on strong evidence, presented in ways that do not undermine the message itself, and incorporating integrated KT models to ensure rapid uptake and application in the real world.

CNODES: the Canadian Network for Observational Drug Effect Studies.

Although administrative health care databases have long been used to evaluate adverse drug effects, responses to drug safety signals have been slow and uncoordinated. We describe the establishment of the Canadian Network for Observational Drug Effect Studies (CNODES), a collaborating centre of the Drug Safety and Effectiveness Network (DSEN). CNODES is a distributed network of investigators and linked databases in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec and Nova Scotia. Principles of operation are as follows: (1) research questions are prioritized by the coordinating office of DSEN; (2) the linked data stay within the provinces; (3) for each question, a study team formulates a detailed protocol enabling consistent analyses in each province; (4) analyses are "blind" to results obtained elsewhere; (5) protocol deviations are permitted for technical reasons only; (6) analyses using multivariable methods are lodged centrally with a methods team, which is responsible for combining the results to provide a summary estimate of effect. These procedures are designed to achieve high internal validity of risk estimates and to eliminate the possibility of selective reporting of analyses or outcomes. The value of a coordinated multi-provincial approach is illustrated by projects studying acute renal injury with high-potency statins, community-acquired pneumonia with proton pump inhibitors, and hyperglycemic emergencies with antipsychotic drugs. CNODES is an academically based distributed network of Canadian researchers and data centres with a commitment to rapid and sophisticated analysis of emerging drug safety signals in study populations totalling over 40 million.

Suicide and suicide attempts in children and adolescents in the child welfare system.

BACKGROUND: Few population studies have examined the psychiatric outcomes of children and adolescents in the child welfare system, and no studies have compared outcomes before and after entry into care. Our objective was to assess the relative rate (RR) of suicide, attempted suicide, admission to hospital and visits to physicians' offices among children and adolescents in care compared with those not in care. We also examined these outcomes within the child welfare population before and after entry into care. METHODS: We used population-level data to identify children and adolescents 5 to 17 years of age who were in care in Manitoba for the first time between Apr. 1, 1997, and Mar. 31, 2006, and a comparison cohort not in care. We compared the two cohorts to obtain RRs for the specified outcomes. We also determined RRs within the child welfare population relative to the same population two years before entry into care. RESULTS: We identified 8279 children and adolescents in care for the first time and a comparison cohort of 353 050 children and adolescents not in care. Outcome rates were higher among those in care than in the comparison cohort for suicide (adjusted RR 3.54, 95% confidence interval [CI] 2.11-5.95), attempted suicide (adjusted RR 2.11, 95% CI 1.84-2.43) and all other outcomes. However, adjusted RRs for attempted suicide (RR 0.27, 95% CI 0.21-0.34), admissions to hospital and physician visits decreased after entry into care. INTERPRETATION: Children and adolescents in care were at greater risk of suicide and attempting suicide than those who were not in care. Rates of suicide attempts and hospital admissions within this population were highest before entry into care and decreased thereafter.

What is the comparative health status and associated risk factors for the Métis? A population-based study in Manitoba, Canada.

BACKGROUND: Métis are descendants of early 17th century relationships between North American Indians and Europeans. This study's objectives were: (1) to compare the health status of the Métis people to all other residents of Manitoba, Canada; and (2) to analyze factors in predicting the likelihood of diabetes and related lower limb amputation. METHODS: Using de-identified administrative databases plus the Métis Population Database housed at the Manitoba Centre for Health Policy, age/sex-adjusted rates of mortality and disease were calculated for Métis (n = 73,016) and all other Manitobans (n = 1,104,672). Diseases included: hypertension, arthritis, diabetes, ischemic heart disease (age 19+); osteoporosis (age 50+); acute myocardial infarction (AMI) and stroke (age 40+); total respiratory morbidity (TRM, all ages). Using logistic regression, predictors of diabetes (2004/05-2006/07) and diabetes-related lower-limb amputations (2002/03-2006/07) were analyzed. RESULTS: Disease rates were higher for Métis compared to all others: premature mortality before age 75 (4.0 vs. 3.3 per 1000, p < .001); total mortality (9.7 vs. 8.4 per 1000, p < .001); injury mortality (0.58 vs. 0.51 per 1000, p < .03); Potential Years of Life Lost (64.6 vs. 54.6 per 1000, p < .001); all-cause 5-year mortality for people with diabetes (20.8% vs. 18.6%, p < .02); hypertension (27.9% vs. 24.8%, p < .001); arthritis (24.2% vs. 19.9%, p < .001), TRM (13.6% vs. 10.6%, p < .001); diabetes (11.8% vs. 8.8%, p < .001); diabetes-related lower limb amputation (24.1 vs. 16.2 per 1000, p < .001); ischemic heart disease (12.2% vs. 8.7%, p < .001); osteoporosis (12.2% vs. 12.3%, NS), dialysis initiation (0.46% vs. 0.34%, p < .001); AMI (5.4 vs. 4.3 per 1000, p < .001); stroke (3.6 vs. 2.9 per 1000, p < .001). Controlling for geography, age, sex, income, continuity of care and comorbidities, Métis were more likely to have diabetes (aOR = 1.29, 95% CI 1.25-1.34), but not diabetes-related lower limb amputation (aOR = 1.13, 95% CI 0.90-1.40, NS). Continuity of care was associated with decreased risk of amputation both provincially (aOR = 0.71, 95% CI 0.62-0.81) and for Métis alone (aOR = 0.62, 95% CI 0.40-0.96). CONCLUSION: Despite universal healthcare, Métis' illness and mortality rates are mostly higher. Although elevated diabetes risk persists for the Métis even after adjusting for sociodemographic, healthcare and comorbidity variables, the risk of amputation for Métis appears more related to healthcare access rather than ethnicity.

Conservation of resources theory and research use in health systems.

BACKGROUND: Health systems face challenges in using research evidence to improve policy and practice. These challenges are particularly evident in small and poorly resourced health systems, which are often in locations (in Canada and globally) with poorer health status. Although organizational resources have been acknowledged as important in understanding research use resource theories have not been a focus of knowledge translation (KT) research. What resources, broadly defined, are required for KT and how does their presence or absence influence research use?In this paper, we consider conservation of resources (COR) theory as a theoretical basis for understanding the capacity to use research evidence in health systems. Three components of COR theory are examined in the context of KT. First, resources are required for research uptake. Second, threat of resource loss fosters resistance to research use. Third, resources can be optimized, even in resource-challenged environments, to build capacity for KT. METHODS: A scan of the KT literature examined organizational resources needed for research use. A multiple case study approach examined the three components of COR theory outlined above. The multiple case study consisted of a document review and key informant interviews with research team members, including government decision-makers and health practitioners through a retrospective analysis of four previously conducted applied health research studies in a resource-challenged region. RESULTS: The literature scan identified organizational resources that influence research use. The multiple case study supported these findings, contributed to the development of a taxonomy of organizational resources, and revealed how fears concerning resource loss can affect research use. Some resources were found to compensate for other resource deficits. Resource needs differed at various stages in the research use process. CONCLUSIONS: COR theory contributes to understanding the role of resources in research use, resistance to research use, and potential strategies to enhance research use. Resources (and a lack of them) may account for the observed disparities in research uptake across health systems. This paper offers a theoretical foundation to guide further examination of the COR-KT ideas and necessary supports for research use in resource-challenged environments.

Demographic and social variables associated with problem gambling among men and women in Canada.

Knowledge of demographic and social correlates of problem gambling among men and women in general population samples is limited. Such research is important for identifying individuals who may become problem gamblers. The current research used a gender-stratified analysis using logistic regression models in a nationally representative sample to identify correlates of problem gambling among men and women. Data were from the Canadian Community Health Survey Cycle 1.2 (CCHS 1.2; data collected in 2002; response rate 77%). The 12-month prevalence of problem gambling among men and women who endorsed gambling in the past year was 4.9% and 2.7%, respectively. For women, increased odds of problem gambling was associated with middle age, middle to low levels of income, a high school diploma or less, being never-married, higher levels of life stress, and negative coping abilities. For men, being aged 70 or greater decreased the odds of problem gambling, while being separated, widowed, or divorced, lower levels of social support, and negative coping abilities increased the odds of problem gambling. These findings have important public health implications for identifying men and women who may be more likely to become problem gamblers in the general population.

Pediatric appendicitis rupture rate: disparities despite universal health care.

BACKGROUND/PURPOSE: Significant socioeconomic disparities have been observed in the rates of perforated appendicitis among children in private health care. We seek to explore if, in the Canadian system of public, universal health care access, pediatric appendicitis rupture rates are an indicator of health disparities. METHODS: Using the Population Health Research Data Repository housed at Manitoba Centre for Health Policy, a retrospective analysis over a 20-year period (1983-2003) examined all patients aged less than 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes for appendicitis (N = 7475). Multivariate logistic regression analysis was used to calculate odds ratios in the association between appendiceal rupture rates and the patient's socioeconomic status (SES) based upon average household income of the census area adjusted for age, sex, area of residence, and treating hospital. RESULTS: The overall appendiceal rupture rate was 28.8%. Significant positive predictors of appendiceal rupture were lower rural SES, lower urban SES, younger age, northern area of residence, and receiving treatment at the province's only pediatric tertiary care hospital. CONCLUSION: Despite free, universal access health care, children from lower SES areas have increased appendiceal rupture rates. Seeking and accessing medical attention can be complicated by social, behavioral, and geographical problems.

How health status affects progress and performance in school: a population-based study.

OBJECTIVE: To assess the effects of health status at birth and health status in the preschool years on educational outcomes to age 9 in a population-based birth cohort. METHODS: Administrative data were used to follow all children born to Winnipeg mothers in 1990, and remaining in Manitoba until September 2004 (N = 5,873). A structural equation model was used, incorporating latent variables to represent Health Status at Birth, Major Illness and Minor Illness during the preschool years. The model also included the child's sex and exact age, along with a number of social, economic, and demographic characteristics of the child's family. The outcome was a combination of marks on Grade 3 Standards Tests and enrollment in the appropriate grade for age. RESULTS: Major Illness in the preschool years had a significant influence on progress and performance in school (p = 0.0003), predicting 1.26% of the variation in the outcome. Minor Illness was weaker but still significant (p < 0.01). Health Status at Birth was not directly related to the outcome; its effect was mediated by Major and Minor Illness in childhood. Overall, the strongest predictors were the child's age and the area-level income, followed by the mother's age, family receipt of income assistance, the sex of the child, breastfeeding initiation (all p < 0.0001), and Major Illness. CONCLUSIONS: Health status plays a statistically significant but substantively small role in explaining progress and performance in school among a population-based cohort. Major Illness was more important than Minor Illness, and these two factors completely mediated the influence of Health Status at Birth on the outcome. The strength of the social, economic, and demographic variables underscores the importance of the broader factors that affect both health and educational outcomes.

Bringing safety and responsiveness into the forefront of care for pregnant and parenting aboriginal people.

Poor access to prenatal care for Aboriginal people is well documented, and is explicated as an unethical barrier to care resulting from colonial and neocolonial values, attitudes, and practices. A postcolonial standpoint, participatory research principles, and a case study design were used to investigate 2 Aboriginal organizations' experiences improving care for pregnant and parenting Aboriginal people. Data were collected through exploratory interviews and small-group discussions with purposefully selected community leaders, providers, and community members. The study found that safety in healthcare relationships and settings, and responsiveness to individuals' and families' unique experiences and capacities must be brought into the forefront of care. Results suggest that the intention of care must be situated within a broader view of colonizing relations to improve early access to, and relevance of, care during pregnancy and parenting for Aboriginal people.

Health services use of Manitoba First Nations people: is it related to underlying need?

BACKGROUND: To compare health status and health services use of Registered First Nations to all other Manitobans (AOM). If the Canadian health care system is meeting underlying need, those experiencing the greatest burden of morbidity and mortality should show the highest rates of health service use. METHODS: Registered First Nations' (n = 85,959) hospitalization and physician visit rates were compared to rates of all other Manitobans (n = 1,054,422) for fiscal year 1998/99. The underlying "need" for health care was measured using premature mortality (PMR), an age- and sex-adjusted rate of death before age 75. Data were derived from Manitoba's Population Health Research Data Repository, linked to federal Status Verification System files to determine Registered First Nations status. RESULTS: Registered First Nations' PMR was double the rate of all other Manitobans (6.61 vs. 3.30 deaths per thousand, p < 0.05). Registered First Nations ambulatory physician visit rates (6.13 vs. 4.85 visits per person, p < 0.05), hospital separation rates (0.348 vs. 0.156 separations per person, p < 0.05) and total days of hospital care (1.75 vs. 1.05 days per person, p < 0.05) were higher than AOM rates. Consultation rates (first visit to a specialist) were slightly higher for Registered First Nations (0.29 vs. 0.27 visits per person, p < 0.05), and overall specialist visit rates were lower (0.895 vs. 1.284 visits per person, p < 0.05) compared with AOM. CONCLUSION: Although hospitalization and ambulatory physician visit rates for First Nations reflect their poorer health status, consult and specialist rates do not reflect the underlying need for health care services.

Mortality comparisons of First Nations to all other Manitobans: a provincial population-based look at health inequalities by region and gender.

BACKGROUND: To examine inequalities in health status of Registered First Nations Manitobans compared to all other Manitobans. METHODS: Three mortality indicators--premature mortality rate (PMR) defined as an age- and sex-adjusted rate of death before age 75 years; life expectancy from birth; and potential years of life lost (PYLL)--are compared between Registered First Nations (RFN) people and all other Manitobans (AOM) by geographical areas of Manitoba. Data were derived from the Population Health Research Data Repository, linked to the federal Status Verification System (SVS) files for the years 1995 through 1999. RESULTS: First Nations experienced double the PMR compared to all other Manitobans (6.6 versus 3.3 deaths per thousand, p < 0.05), an eight-year gap in life expectancy (males: 68.4 versus 76.1 years; females 73.2 versus 81.4 years), and over twice the PYLL (males 158.3 versus 62.5 years of life lost per thousand; females 103.3 versus 36.5). RFN male life expectancy was geographically-related (better health status in the north), and inversely related to the corresponding regional AOM life expectancy (r = -0.61, 9 df, one-tailed, p < 0.03). As regional percentage of RFN decreased, male life expectancy decreased (r = 0.77, 9 df, one-tailed, p < 0.003). In contrast, RFN female indicators showed no such relationship. CONCLUSION: The inequality in health status between RFN and all other Manitobans is large, but also shows differential geographical and gender effects.

Predictors of hospital readmission of Manitoba newborns within six weeks postbirth discharge: a population-based study.

OBJECTIVES: To examine the proportion, geographic variation, and predictors of infant hospital readmission within 6 weeks of the postbirth discharge. METHODS: A cross-sectional, population-based study was conducted of all infants who were born from 1997 through 2001, linkable to the birth mother, and discharged alive from the hospital (N = 68 681) using hospital discharge files in the Canadian province of Manitoba. The following predictors of readmission were examined using logistic regression: preterm, low birth weight, neighborhood income, geographic location (the North, Rural South, and Urban areas of Winnipeg and Brandon), breastfeeding status, length of stay, maternal age, and type of delivery. Using 9 non-Winnipeg regions and 12 Winnipeg subregions, ecologic correlations (1-tailed Spearman) between newborn hospital readmission rates and the following were examined: 1) a region's overall health status, measured by the premature mortality rate (PMR), or death before aged 75 years and 2) a region's socioeconomic risk, using the Socio-Economic Factor Index (SEFI). RESULTS: The proportion of infants who were readmitted to the hospital at least once within 6 weeks of postbirth hospital discharge was 3.95%, with respiratory illness the leading cause (22.3% of readmissions). Risk of readmission was higher for infants who were born preterm (adjusted odds ratio [AOR]: 1.80; 95% confidence interval [CI]: 1.55-2.10), who were of the 3 lowest income quintiles (lowest: AOR: 2.02; 95% CI: 1.77-2.32; low: AOR: 1.48; 95% CI: 1.29-1.71; middle: AOR: 1.26; 95% CI: 1.08-1.47), who resided in the North (AOR: 1.85; 95% CI: 1.66-2.07) or Rural South (AOR: 1.25; 95% CI: 1.14-1.36), who were not breastfed (AOR: 1.32; 95% CI: 1.20-1.44), whose mother's age was 17 or younger (AOR: 1.30; 95% CI: 1.10-1.55), whose mother was 18 to 19 years of age (AOR: 1.25; 95% CI: 1.09-144), or who were born by cesarean section (AOR: 1.30; 95% CI: 1.19-1.43). Regional readmission rates were correlated with PMR (9 non-Winnipeg regions: r = 0.77 for PMR and r = 0.68 for SEFI; 12 Winnipeg Community Areas: r = 0.49 for PMR and r = 0.73 for SEFI). CONCLUSIONS: Income and geography are strongly associated with newborn hospital readmission. Modifiable risk factors include increasing breastfeeding rates, decreasing cesarean section rates, and decreasing adolescent pregnancy rates (or increasing adolescent parental support), but these need additional study to establish causation.

Type 2 diabetes mellitus in children: prenatal and early infancy risk factors among native canadians.

BACKGROUND: Type 2 diabetes mellitus is increasingly being observed among children and youth, including the Native population of Canada. Only one study has investigated prenatal and early infancy risk factors for the disease. METHODS: A case-control study was conducted; 46 patients younger than 18 years were recruited from the only clinical center for the treatment of diabetes serving the province of Manitoba, and 92 age- and sex-matched controls were recruited from a pediatric ambulatory clinic serving a large Native population in Winnipeg, Manitoba. Information on exposure to prenatal and early infancy risk factors was obtained through questionnaires administered by a Native nurse-interviewer. RESULTS: Multiple logistic regression modeling identified preexisting diabetes (odds ratio [OR], 14.4; 95% confidence interval [CI], 2.86-72.5), gestational diabetes (OR, 4.40; 95% CI, 1.38-14.1), and breastfeeding longer than 12 months (OR, 0.24; 95% CI, 0.13-0.99) as significant independent predictors of diabetic status. Other factors, such as low (<2500 g) and high (>4000 g) birth weight and maternal obesity, were also associated with diabetes in our population, but the elevated risks were not statistically significant. CONCLUSION: Breastfeeding reduces the risk of type 2 diabetes among Native Canadian children and should be promoted as a potential intervention to control the disease.

Embedding child health within a framework of regional health: population health status and sociodemographic indicators.

OBJECTIVE: The description of regional variation in children's health requires regional population-based context. But what is the best way to measure the health of a region's population? METHODS: The use of two indicators is described--one a health status measure and the other a measure of socioeconomic wellbeing. It is well known that the population's premature mortality rate (PMR), the age/sex-adjusted rate of death before age 75 years, is highly related to overall health status of an area's residents. Socioeconomic characteristics of an area's residents are also indicative (and likely causative) of health status differences. RESULTS: The Socioeconomic Factor Index (SEFI) was developed at the Manitoba Centre for Health Policy, using a Principal Components Analysis of census data. PMR and SEFI are highly correlated (Spearman's correlation coefficient r = 0.85, p < 0.0001). CONCLUSION: PMR can be used as a surrogate measure for both the health status and socioeconomic well-being of regional populations in Manitoba.