Multifetal Pregnancy After Implementation of a Publicly Funded Fertility Program.

Importance: A publicly funded fertility program was introduced in Ontario, Canada, in 2015 to increase access to fertility treatment. For in vitro fertilization (IVF), the program mandated an elective single-embryo transfer (eSET) policy. However, ovulation induction and intrauterine insemination (OI/IUI)-2 other common forms of fertility treatment-were more difficult to regulate in this manner. Furthermore, prior epidemiologic studies only assessed fetuses at birth and did not account for potential fetal reductions that may have been performed earlier in pregnancy. Objective: To examine the association between fertility treatment and the risk of multifetal pregnancy in a publicly funded fertility program, accounting for both fetal reductions and all live births and stillbirths. Design, Setting, and Participants: This population-based, retrospective cohort study used linked administrative health databases at ICES to examine all births and fetal reductions in Ontario, Canada, from April 1, 2006, to March 31, 2021. Exposure: Mode of conception: (1) unassisted conception, (2) OI/IUI, or (3) IVF. Main Outcomes and Measures: The main outcome was multifetal pregnancy (ie, a twin or higher-order pregnancy). Modified Poisson regression generated adjusted relative risks (ARRs) and derived population attributable fractions (PAFs) for multifetal pregnancies attributable to fertility treatment. Absolute rate differences (ARDs) were used to compare the era before eSET was promoted (2006-2011) with the era after the introduction of the eSET mandate (2016-2021). Results: Of all 1 724 899 pregnancies, 1 670 825 (96.9%) were by unassisted conception (mean [SD] maternal age, 30.6 [5.2] years), 24 395 (1.4%) by OI/IUI (mean [SD] maternal age, 33.1 [4.4] years), and 29 679 (1.7%) by IVF (mean [SD] maternal age, 35.8 [4.7] years). In contrast to unassisted conception, individuals who received OI/IUI or IVF tended to be older, reside in a high-income quintile neighborhood, or have preexisting health conditions. Multifetal pregnancy rates were 1.4% (95% CI, 1.4%-1.4%) for unassisted conception, 10.5% (95% CI, 10.2%-10.9%) after OI/IUI, and 15.5% (95% CI, 15.1%-15.9%) after IVF. Compared with unassisted conception, the ARR of any multifetal pregnancy was 7.0 (95% CI, 6.7-7.3) after OI/IUI and 9.9 (95% CI, 9.6-10.3) after IVF, with corresponding PAFs of 7.1% (95% CI, 7.1%-7.2%) and 13.4% (95% CI, 13.3%-13.4%). Between the eras of 2006 to 2011 and 2016 to 2021, multifetal pregnancy rates decreased from 12.9% to 9.1% with OI/IUI (ARD, -3.8%; 95% CI, -4.2% to -3.4%) and from 29.4% to 7.1% with IVF (ARD, -22.3%; 95% CI, -23.2% to -21.6%). Conclusions and Relevance: In this cohort study of more than 1.7 million pregnancies in Ontario, Canada, a publicly funded IVF program mandating an eSET policy was associated with a reduction in multifetal pregnancy rates. Nevertheless, ongoing strategies are needed to decrease multifetal pregnancy, especially in those undergoing OI/IUI.

Safety of prenatal opioid analgesics: Do results differ between public health insurance beneficiary and population-based cohorts?

BACKGROUND: Pregnant patients with particular types of health insurance may have distinct demographic and medical characteristics that have a biologic effect on associations between opioid analgesics and congenital anomalies (CA). METHODS: We followed 199,884 pregnant prescription beneficiaries in Ontario, Canada (1996-2018). Opioid analgesics dispensed in the first trimester and CA were identified from universal-access administrative health records. We estimated propensity score adjusted risk ratios (RR) between first trimester exposure and CA (any, major, minor, specific). RRs were compared to those published from an Ontario population-based cohort (N = 599,579, 2013-2018). RESULTS: 15,724 (7.9%) were exposed to first trimester opioid analgesics, mainly codeine (58.1%) or oxycodone (21.3%); CA prevalence in exposed was 3.1%. RRs in the beneficiary cohort appeared higher than the population-based cohort for any CA with hydromorphone (RR = 2.34, 95% CI: 1.65, 3.30) and oxycodone (RR = 1.73, 95% CI: 1.46, 2.05) and major CA with hydromorphone (RR = 2.74, 95% CI: 1.91, 3.94) and oxycodone (RR = 1.72, 95% CI: 1.42, 2.08). Other RRs that appeared higher in the beneficiary cohort included cardiovascular (codeine, oxycodone), gastrointestinal (oxycodone), musculoskeletal (any, hydromorphone, oxycodone), CNS (oxycodone), chromosomal (codeine), and neoplasm and tumor (oxycodone) anomalies. The beneficiary cohort had higher opioid doses, was younger, had lower socioeconomic status, and greater comorbidities. CONCLUSIONS: Increased risks of CA after first trimester opioid analgesics were observed in low-income prescription beneficiaries, and some estimates were higher than a population-based cohort from the same setting. Biological differences associated with younger age, lower socioeconomic status and greater comorbidity may affect generalizability of results from pregnant low-income beneficiaries.

The cost of preterm birth and cesarean section as a result of infertility and its treatment: A review.

Infertility, irrespective of receipt of fertility treatment, is associated with an increased risk of adverse pregnancy outcomes, including cesarean section (CS) and preterm birth (PTB). These complications are associated with significant physical, mental, emotional, social, and financial costs to individuals, healthcare systems, and society at large. Although multiple pregnancy is one of the most significant contributors to the elevated CS and PTB rates in women receiving fertility treatment, singleton pregnancy is also at an increased risk of these outcomes. Single embryo transfer policies through publicly funded in vitro fertilization programs have demonstrated beneficial health outcomes and cost savings. Low-dose aspirin prophylaxis may be considered for PTB reduction in patients with infertility. Finally, upstream prevention strategies such as lifestyle modification and social policies to address the underlying needs for fertility treatment may also beneficially impact both CS and PTB rates.

Prescribed opioid analgesics in early pregnancy and the risk of congenital anomalies: a population-based cohort study.

BACKGROUND: Recent data suggest an increased risk of congenital anomalies with prenatal exposure to opioid analgesics. We sought to further quantify the risk of anomalies after opioid analgesic exposure during the first trimester in a population-based cohort study. METHODS: Using administrative health data from Ontario, we followed 599 579 gestational parent-infant pairs from singleton pregnancies without opioid use disorder. We identified opioid analgesics dispensed in the first trimester and congenital anomalies diagnosed during the first year of life. We estimated propensity score-adjusted risk ratios (RRs) between first trimester exposure (any opioid analgesic and specific agents) and congenital anomalies (any anomaly, organ system anomalies, major or minor anomalies and specific anomalies). RESULTS: The prevalence of congenital anomalies was 2.8% in exposed infants and 2.0% in unexposed infants. Relative to unexposed infants, we observed elevated risks among those who were exposed for some anomaly groups, including gastrointestinal anomalies (any opioid analgesic: adjusted RR 1.46, 95% confidence interval [CI] 1.15-1.85; codeine: adjusted RR 1.53, 95% CI 1.12-2.09; tramadol: adjusted RR 2.69, 95% CI 1.34-5.38) and several specific anomalies, including ankyloglossia (any opioid: adjusted RR 1.88, 95% CI 1.30-2.72; codeine: adjusted RR 2.14, 95% CI 1.35-3.40). These findings persisted in sensitivity analyses. INTERPRETATION: Although the absolute risk of congenital anomalies was low, our findings add to accumulating data that suggest a small increased risk of some organ system anomalies and specific anomalies with first trimester exposure to opioid analgesics. These findings further quantify the potential risks associated with prenatal exposure to opioid analgesics to inform treatment choices for pain in pregnancy.

Evaluating Health Literacy among Adolescent and Young Adult Pregnant Women from a Low-Income Area of Northeast Brazil.

Adequate health literacy is important for strong health outcomes during pregnancy, particularly among mothers with high risk of adverse outcomes related to pregnancy and childbirth. Understanding the health literacy of young pregnant women in low-income settings could support strategies to reduce adverse outcomes in this population. This exploratory study assessed the health literacy of young pregnant adolescents and young adults from a rural area in Northeast Brazil and associated factors such as socioeconomic conditions, adequacy of prenatal care, and social support from family and friends. In this cross-sectional study, 41 pregnant adolescents (13-18 years) and 45 pregnant adults (23-28 years) from the Rio Grande do Norte state, Brazil, were assessed regarding health literacy through the Short Assessment of Health Literacy for Portuguese-Speaking Adults (SAHLPA, score from 0-18, inadequate if <15). Income sufficiency, self-perceived school performance, compliance with recommendations for adequate prenatal care, and social support were also assessed. A linear regression analysis was conducted to evaluate the variables associated with the SAHLPA score. Ninety-five percent of the adolescents and 53.3% of the adults (p < 0.001) presented inadequate health literacy. Adolescent age (ß - 3.5, p < 0.001), poorer self-perceived school performance (ß - 2.8, p < 0.001), and insufficient income for basic needs (ß - 2.8, p = 0.014) were associated with worse SAHLPA scores. Adolescent mothers have higher rates of inadequate health literacy in this population. Policies are needed to improve access to health information for young populations from rural low-income areas.

The influence of poverty and social support on the perceived health of children born to minority migrant mothers.

OBJECTIVE: Poverty and low social support are common among minority migrant families. Little is known about their impact on the health of children of minority migrants to Canada. This study examined the associations between maternal perception of child's health and migration status, and examined the specific role of poverty and low social support in these associations. DESIGN: Data from the first two rounds of the Quebec Longitudinal Study of Child Development (QLSCD) were analysed. The sample included 1990 children at 17 months of age, classified according to their mother's migration status: children of minority migrant mothers (n=165) and Canadian-born mothers (n=1825). Maternal perception of child's health status and social support were measured at 17 months, household income was measured at 5 and 17 months. Multivariable logistic regressions were performed; interactions of migration status with poverty and social support were tested. RESULTS: Poverty and low social support were more common among minority migrant mothers than among Canadian-born mothers. Children of minority migrant mothers who were 'never poor' and reported high levels of social support were perceived in better health (OR 0.42; 95% confidence interval (CI): 0.19-0.91) than children of Canadian-born mothers (reference group). In contrast, children of minority migrant mothers who were 'always poor' and reported low social support were perceived in worse health (OR 6.32; 95% CI: 1.69-23.71) compared to the reference group. CONCLUSION: In Quebec, economic hardship and lack of social support are common realities among minority migrants with young children. Combined exposure to poverty and low social support is most detrimental to the perceived health of children of minority migrants.

Life course socioeconomic adversity and age at natural menopause in women from Latin America and the Caribbean.

OBJECTIVE: The aim of this study was to assess the association between life course socioeconomic adversity and age at menopause in Latin America and the Caribbean. METHODS: Data from 4,056 women aged 60 to 79 years randomly selected from seven cities in Latin America and the Caribbean were analyzed. Cox proportional hazards models were used to estimate the probability of age at menopause by indicators of life course socioeconomic adversity. RESULTS: Median age at menopause was 50 years. The following life course socioeonomic indicators were associated with earlier age at menopause: low education (hazard ratio [HR], 1.16; 95% CI, 1.07-1.26) and manual occupation/housewives (HR, 1.12; 95% CI, 1.03-1.20). Other factors associated with earlier age at menopause were current smoking (HR, 1.14; 95% CI, 1.03-1.27), nulliparity (HR, 1.14; 95% CI, 1.02-1.28), and multiparity (five children or more; HR, 1.15; 95% CI, 1.06-1.24). There was a cumulative effect of socioeconomic adversities across the life course. The median age at menopause was lower for women with six indicators of life course socioeconomic adversity compared with women with no adversities (HR, 1.40; 95% CI, 1.10-1.77). CONCLUSIONS: Median age at menopause occurs several years earlier in women from Latin America and the Caribbean compared with women from high-income countries. The results support the association between life course socioeconomic adversity and age at menopause.