Preconception health disparities among reproductive-aged women with and without disabilities in Canada.

OBJECTIVES: Preconception health (PCH), which describes the health status of reproductive-aged individuals, can influence reproductive, maternal, and fetal/neonatal outcomes. PCH disparities have been observed in certain populations, prompting the development of tailored resources. Our objective was to compare the PCH characteristics of women with and without disabilities. METHODS: We undertook a secondary analysis of the 2003-2014 cycles of the Canadian Community Health Survey (CCHS), which included n = 115,295 women aged 15-49 years. Among these, we also examined a sub-sample of n = 12,495 women with a subsequent obstetrical delivery identified in a linkage of the CCHS with the Discharge Abstract Database (DAD, 2003-2017). The outcomes were 8 PCH indicators. We used modified Poisson regression to estimate adjusted prevalence ratios (aPRs) for each PCH indicator, comparing women with and without disabilities, and multinomial logistic regression to calculate adjusted odds ratios for 1, 2, and ≥ 3 PCH indicators (vs. 0). Analyses were adjusted for baseline demographics. RESULTS: Reproductive-aged women with disabilities had significantly increased aPRs of smoking (1.42 [95% CI:1.37-1.48]), obesity (1.57 [1.48-1.65]), and self-reported fair/poor physical (5.56 [5.09-6.07]) and mental health (4.07 [3.71-4.47]), compared to those without disabilities. They were also more likely to have ≥ 3, 2, and 1 PCH indicators (vs. 0). Findings were similar in the sub-sample with a subsequent obstetrical delivery. CONCLUSION: Canadian reproductive-aged women with disabilities experience important PCH disparities. Further research is needed to inform tailored education and resources to support PCH in individuals with disabilities, in combination with policies to address structural barriers to PCH.

RéSUMé: OBJECTIFS: La santé préconceptionnelle (SPC), qui décrit l'état de santé des personnes en âge de procréer, peut influencer les résultats reproductifs, maternels et fœtaux/néonataux. Des disparités en matière de SPC ont été observées dans certaines populations, ce qui a conduit à la mise en place de ressources adaptées. Notre objectif était de comparer les caractéristiques de la SPC des femmes handicapées et non handicapées. MéTHODES: Nous avons entrepris une analyse secondaire des cycles 2003­2014 de l'Enquête sur la santé dans les collectivités canadiennes (ESCC), qui comprenait n = 115 295 femmes âgées de 15 à 49 ans. Parmi celles-ci, nous avons également examiné un sous-échantillon de n = 12 495 femmes ayant subi un accouchement obstétrique subséquent, identifiées dans le cadre d'un couplage de l'ESCC avec la Base de données sur les congés des patients (BDCP, 2003‒2017). Les résultats étaient 8 indicateurs de la SPC. Nous avons utilisé la régression de Poisson modifiée pour estimer les ratios de prévalence ajustés (aPR) pour chaque indicateur SPC, en comparant les femmes avec et sans handicap, et la régression logistique multinomiale pour calculer les rapports de cotes ajustés pour 1, 2 et ≥ 3 indicateurs SPC (par rapport à 0). Les analyses ont été ajustées en fonction des données démographiques de base. RéSULTATS: Les femmes handicapées en âge de procréer présentaient des aPR significativement plus élevés de tabagisme (1,42 [IC 95%: 1,37 à 1,48]), d'obésité (1,57 [1,48 à 1,65]) et de santé physique (5,56 [5,09 à 6,07]) et mentale (4,07 [3,71 à 4,47]) auto déclarée passable/mauvaise, par rapport à celles qui n'avaient pas de handicap. Elles étaient également plus susceptibles d'avoir ≥ 3, 2 et 1 indicateurs SPC (par rapport à 0). Les résultats étaient similaires dans le sous-échantillon avec un accouchement obstétrical ultérieur. CONCLUSION: Les femmes handicapées en âge de procréer au Canada connaissent d'importantes disparités en matière de SPC. D'autres recherches sont nécessaires pour fournir une éducation et des ressources adaptées afin de soutenir la SPC chez les personnes handicapées, en combinaison avec des politiques visant à éliminer les obstacles structurels à la SPC.

Mental Illness in the 2 Years Prior to Pregnancy in a Population With Traumatic Brain Injury: A Cross-Sectional Study: La maladie mentale dans les deux ans précédant une grossesse dans une population souffrant de lésion cérébrale traumatique : une étude transversale.

OBJECTIVE: Existing studies, in mostly male samples such as veterans and athletes, show a strong association between traumatic brain injury (TBI) and mental illness. Yet, while an understanding of mental health before pregnancy is critical for informing preconception and perinatal supports, there are no data on the prevalence of active mental illness before pregnancy in females with TBI. We examined the prevalence of active mental illness ≤2 years before pregnancy (1) in a population with TBI, and (2) in subgroups defined by sociodemographic, health, and injury-related characteristics, all compared to those without TBI. METHOD: This population-based cross-sectional study was completed in Ontario, Canada, from 2012 to 2020. Modified Poisson regression generated adjusted prevalence ratios (aPRs) of active mental illness ≤2 years before pregnancy in 15,585 females with TBI versus 846,686 without TBI. We then used latent class analysis to identify subgroups with TBI according to sociodemographic, health, and injury-related characteristics and subsequently compared them to females without TBI on their outcome prevalence. RESULTS: Females with TBI had a higher prevalence of active mental illness ≤2 years before pregnancy than those without TBI (44.1% vs. 25.9%; aPR 1.46, 95% confidence interval, 1.43 to 1.49). There were 3 TBI subgroups, with Class 1 (low-income, past assault, recent TBI described as intentional and due to being struck by/against) having the highest outcome prevalence. CONCLUSIONS: Females with TBI, and especially those with a recent intentional TBI, have a high prevalence of mental illness before pregnancy. They may benefit from mental health screening and support in the post-injury, preconception, and perinatal periods. PLAIN LANGUAGE TITLE: Mental illness in the 2 years before pregnancy in a population with traumatic brain injury. PLAIN LANGUAGE SUMMARY: Research has shown a strong association between traumatic brain injury (TBI) and mental illness. Most previous studies have been conducted in primarily male samples, like veterans and professional athletes. Understanding mental health before pregnancy is important for deciding what supports people need before and during pregnancy. However, there are no studies on the frequency of mental illness in females with TBI before a pregnancy. We examined the frequency of mental illness 2 years before pregnancy in a population with TBI, and in subgroups defined by different social, health, and injury-related characteristics, compared to those without TBI. We undertook a population-wide study of all females with and without TBI in Ontario, Canada, with a birth in 2012-2020. We used statistical models to compare these groups on the presence of mental illness in the 2 years before pregnancy, before and after accounting for social and health characteristics. We also identified subgroups with TBI according to their social (e.g., poverty), health (e.g., chronic conditions), and injury-related characteristics (e.g., cause of injury) and subsequently compared them to females without TBI on their frequency of mental illness in the 2 years before pregnancy. Forty-four percent of females with TBI had mental illness in the 2 years before pregnancy compared to 25% of those without TBI. There were 3 TBI subgroups. Females with low-income, past assault, and injuries that were described as being intentional had the highest frequency of mental illness in the 2 years before pregnancy. Females with TBI may benefit from mental health screening and support post-injury and around the time of pregnancy.

Teen Pregnancy and Risk of Premature Mortality.

Importance: Unintentional injury, suicide, and homicide are leading causes of death among young females. Teen pregnancy may be a marker of adverse life experiences. Objective: To evaluate the risk of premature mortality from 12 years of age onward in association with number of teen pregnancies and age at pregnancy. Design, Setting, and Participants: This population-based cohort study was conducted among all females alive at 12 years of age from April 1, 1991, to March 31, 2021, in Ontario, Canada (the most populous province, which has universal health care and data collection). The study period ended March 31, 2022. Exposures: The main exposure was number of teen pregnancies between 12 and 19 years of age (0, 1, or ≥2). Secondary exposures included how the teen pregnancy ended (birth or miscarriage vs induced abortion) and age at first teen pregnancy. Main Outcomes and Measures: The main outcome was all-cause mortality starting at 12 years of age. Hazard ratios (HRs) were adjusted for year of birth, comorbidities at 9 to 11 years of age, and area-level education, income level, and rurality. Results: Of 2 242 929 teenagers, 163 124 (7.3%) experienced a pregnancy at a median age of 18 years (IQR, 17-19 years). Of those with a teen pregnancy, 60 037 (36.8%) ended in a birth (of which 59 485 [99.1%] were live births), and 106 135 (65.1%) ended in induced abortion. The median age at the end of follow-up was 25 years (IQR, 18-32 years) for those without a teen pregnancy and 31 years (IQR, 25-36 years) for those with a teen pregnancy. There were 6030 deaths (1.9 per 10 000 person-years [95% CI, 1.9-2.0 per 10 000 person-years]) among those without a teen pregnancy, 701 deaths (4.1 per 10 000 person-years [95% CI, 3.8-4.5 per 10 000 person-years]) among those with 1 teen pregnancy, and 345 deaths (6.1 per 10 000 person-years [95% CI, 5.5-6.8 per 10 000 person-years]) among those with 2 or more teen pregnancies; adjusted HRs (AHRs) were 1.51 (95% CI, 1.39-1.63) for those with 1 pregnancy and 2.14 (95% CI, 1.92-2.39) for those with 2 or more pregnancies. Comparing those with vs without a teen pregnancy, the AHR for premature death was 1.25 (95% CI, 1.12-1.40) from noninjury, 2.06 (95% CI, 1.75-2.43) from unintentional injury, and 2.02 (95% CI, 1.54-2.65) from intentional injury. Conclusions and Relevance: In this population-based cohort study of 2.2 million female teenagers, teen pregnancy was associated with future premature mortality. It should be assessed whether supports for female teenagers who experience a pregnancy can enhance the prevention of subsequent premature mortality in young and middle adulthood.

Non-fatal self-harm and suicide following postpartum psychiatric emergency department visits: A population-based retrospective cohort study.

In a population-based cohort of postpartum individuals in Ontario, Canada, this study aimed to determine the risk of non-fatal self-harm and suicide within one year of an initial postpartum psychiatric emergency department (ED) visit (2008-2020), and the key associated factors. Of 16,475 postpartum individuals with psychiatric ED visits, 714 (4.3 %) had non-fatal self-harm within one year, and 23 (0.15 %) died by suicide. Risk was substantially higher for those with self-harm at the initial presentation. Further efforts to connect individuals with postpartum psychiatric ED visits with needed inpatient care and outpatient follow-up are required to reduce non-fatal self-harm and suicide risk.

Use of Latent Class Analysis to Predict Intensive Care Unit Admission and Mortality in Children with a Major Congenital Anomaly.

OBJECTIVE: To define major congenital anomaly (CA) subgroups and assess outcome variability based on defined subgroups. STUDY DESIGN: This population-based cohort study used registries in Denmark for children born with a major CA between January 1997 and December 2016, with follow-up until December 2018. We performed a latent class analysis (LCA) using child and family clinical and sociodemographic characteristics present at birth, incorporating additional variables occurring until age of 24 months. Cox proportional hazards regression models estimated hazard ratios (HRs) of pediatric mortality and intensive care unit (ICU) admissions for identified LCA classes. RESULTS: The study included 27 192 children born with a major CA. Twelve variables led to a 4-class solution (entropy = 0.74): (1) children born with higher income and fewer comorbidities (55.4%), (2) children born to young mothers with lower income (24.8%), (3) children born prematurely (10.0%), and (4) children with multiorgan involvement and developmental disability (9.8%). Compared with those in Class 1, mortality and ICU admissions were highest in Class 4 (HR = 8.9, 95% CI = 6.4-12.6 and HR = 4.1, 95% CI = 3.6-4.7, respectively). More modest increases were observed among the other classes for mortality and ICU admissions (Class 2: HR = 1.7, 95% CI = 1.1-2.5 and HR = 1.3, 95% CI = 1.1-1.4, respectively; Class 3: HR = 2.5, 95% CI = 1.5-4.2 and HR = 1.5, 95% CI = 1.3-1.9, respectively). CONCLUSIONS: Children with a major CA can be categorized into meaningful subgroups with good discriminative ability. These groupings may be useful for risk-stratification in outcome studies.

Sexual and Reproductive Health Outcomes Among Adolescent Females During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Coronavirus disease 2019 (COVID-19) posed a significant threat to adolescents' sexual and reproductive health. In this study, we examined population-level pregnancy and sexual health-related care utilization among adolescent females in Ontario, Canada during the pandemic and evaluated relationships between these outcomes and key sociodemographic characteristics. METHODS: This was a population-based, repeated cross-sectional study of >630 000 female adolescents (12-19 years) during the prepandemic (January 1, 2018-February 29, 2020) and COVID-19 pandemic (March 1, 2020-December 31, 2022) periods. Primary outcome was pregnancy; secondary outcomes were contraceptive management visits, contraception prescription uptake, and sexually transmitted infection (STI) management visits. Poisson models with generalized estimating equations for clustered count data were used to model pre-COVID-19 trends and forecast expected rates during the COVID-19 period. Absolute rate differences between observed and expected outcome rates for each pandemic month were calculated overall and by urbanicity, neighborhood income, immigration status, and region. RESULTS: During the pandemic, lower-than-expected population-level rates of adolescent pregnancy (rate ratio 0.87; 95% confidence interval [CI]:0.85-0.88), and encounters for contraceptive (rate ratio 0.82; 95% CI:0.77-0.88) and STI management (rate ratio 0.52; 95% CI:0.51-0.53) were observed. Encounter rates did not return to pre-pandemic rates by study period end, despite health system reopening. Pregnancy rates among adolescent subpopulations with the highest pre-pandemic pregnancy rates changed least during the pandemic. CONCLUSIONS: Population-level rates of adolescent pregnancy and sexual health-related care utilization were lower than expected during the COVID-19 pandemic, and below-expected care utilization rates persist. Pregnancy rates among more structurally vulnerable adolescents demonstrated less decline, suggesting exacerbation of preexisting inequities.

Perinatal health framework for people with intellectual disability.

We propose a framework for guiding research on perinatal health in people with intellectual disability (ID). We developed this framework based on the perinatal health framework for people with physical disabilities, American Association on Intellectual and Developmental Disabilities conceptual framework of human functioning, disability reproductive justice framework, trauma-informed care, and socio-ecological model. The framework reflects health outcomes of birthing people with ID and their infants that result from interactions of factors across the life course at policy (health, social, and disability policies), community (attitudes, social and physical environment), institutional (health care delivery-related factors, access to information/resources), interpersonal (social determinants of health/histories of trauma, social support, interactions with service-providers), and individual levels (demographics, intellectual functioning, adaptive behavior, health conditions, genetic factors, psychosocial factors, health behaviors). This framework will facilitate research to identify factors leading to perinatal health disparities in people with ID and development and evaluation of resources to address them.

Risk of Repeat Psychiatric Emergency Department Visits in the Postpartum Period: A Population-Based Retrospective Cohort Study.

STUDY OBJECTIVE: Approximately 1 in 100 postpartum individuals visit an emergency department (ED) for a psychiatric reason. Repeat visits can signify problems with the quality of care received during or after the initial visit; this study aimed to understand risk for repeat postpartum psychiatric ED visits. METHODS: This population-based cohort study used Ontario, Canada health administrative data available through ICES (formerly the Institute for Clinical Evaluative Sciences) to identify all individuals discharged from postpartum psychiatric ED visits (2008 to 2021) and measured the proportion with one or more repeat psychiatric ED visit within 30 days. Using modified Poisson regression, we calculated the association between one or more repeat visits and sociodemographic, medical, obstetric, infant, continuity of care, past service use, and index ED visit characteristics both overall and stratified by psychiatric diagnosis. RESULTS: Of 14,100 individuals, 11.7% had one or more repeat psychiatric ED visits within 30 days. Repeat visit risk was highest for those with schizophrenia-spectrum disorders (28.2%, adjusted risk ratio 2.41; 95% confidence interval 1.88 to 3.08, versus 9.5% anxiety referent). Low (versus no) psychiatric care continuity, prior psychiatric ED visits and admissions, and initial visits within 90 days postpartum were also associated with increased risk, whereas intentional self-injury was associated with reduced risk. In diagnosis-stratified analyses, the factors most consistently associated with repeat ED visits were past psychiatric ED visits and admissions, and initial visits within 90 days postpartum. CONCLUSIONS: Over 1 in 10 postpartum psychiatric ED visits are followed by a repeat visit within 30 days. Targeted approaches are needed across clinical populations to reduce repeat ED visits in this population with young infants.

Traditional postpartum rituals among immigrant and non-immigrant Chinese women.

Due to cultural and systemic factors, Chinese-Canadians tend to use mental health services less or when mental health problems are more severe. Services need to be more culturally responsive in their treatment of mental illness. Around important life events, when there may be heightened vulnerability to mental illness, this is especially important. In this study, postpartum cultural practices were examined among recent immigrant, longer-term immigrant, and Canadian-born Chinese women. We conducted a longitudinal cohort study of 493 women in Toronto, Ontario, with livebirths in 2011-2014. Participants completed a demographic survey and Postpartum Rituals Questionnaire. Most women (82.2%) practiced at least one postpartum ritual. Younger age (OR 0.93; 95% CI 0.87-0.99) and greater participation in the heritage culture (OR 1.28; 95% CI 1.02-1.61) were associated with ritual practice. From among five types of postpartum rituals identified (i.e., avoidance of homeostatic disturbances, dietary practices, wind avoidance, organized support, and cold avoidance), dietary practices were most commonly undertaken and cold avoidance was least commonly undertaken. There were differences in postpartum ritual patterns by immigration status, with immigrant women being more likely to undertake a greater number of rituals, to attribute these rituals to Chinese culture, and to ascribe health benefits to these rituals and being less likely to feel forced into performing these rituals. Our findings underscore the importance of clinicians becoming more aware of Chinese postpartum rituals to provide women with culturally competent and patient-centered care.

Patterns of multiple chronic conditions in pregnancy: Population-based study using latent class analysis.

BACKGROUND: Adults with multiple chronic conditions (MCC) are a heterogeneous population with elevated risk of future adverse health outcomes. Yet, despite the increasing prevalence of MCC globally, data about MCC in pregnancy are scarce. OBJECTIVES: To estimate the population prevalence of MCC in pregnancy and determine whether certain types of chronic conditions cluster together among pregnant women with MCC. METHODS: We conducted a population-based cohort study in Ontario, Canada, of all 15-55-year-old women with a recognised pregnancy, from 2007 to 2020. MCC was assessed from a list of 22 conditions, identified using validated algorithms. We estimated the prevalence of MCC. Next, we used latent class analysis to identify classes of co-occurring chronic conditions in women with MCC, with model selection based on parsimony, clinical interpretability and statistical fit. RESULTS: Among 2,014,508 pregnancies, 324,735 had MCC (161.2 per 1000, 95% confidence interval [CI] 160.6, 161.8). Latent class analysis resulted in a five-class solution. In four classes, mood and anxiety disorders were prominent and clustered with one additional condition, as follows: Class 1 (22.4% of women with MCC), osteoarthritis; Class 2 (23.7%), obesity; Class 3 (15.8%), substance use disorders; and Class 4 (22.1%), asthma. In Class 5 (16.1%), four physical conditions clustered together: obesity, asthma, chronic hypertension and diabetes mellitus. CONCLUSIONS: MCC is common in pregnancy, with sub-types dominated by co-occurring mental and physical health conditions. These data show the importance of preconception and perinatal interventions, particularly integrated care strategies, to optimise treatment and stabilisation of chronic conditions in women with MCC.

Adverse perinatal events and maternal interpregnancy weight change: A population-based observational study.

OBJECTIVE: Mothers whose newborn experiences adversity may neglect their own health to care for their affected infant or following a perinatal death. Weight gain after pregnancy is one measure of maternal self-care. We measured interpregnancy weight gain among women whose child had an adverse perinatal event. METHODS: This population-based observational study included 192 154 primigravid women with two consecutive singleton births in Ontario, Canada. Outcomes included net weight gain, and adjusted odds ratios (aOR) of moving to a higher body mass index (BMI) category between pregnancies, comparing women whose child did versus did not experience either a perinatal death, prematurity, severe neonatal morbidity, major congenital anomaly, or severe neurologic impairment. RESULTS: Perinatal death was associated with a +3.5 kg (95% confidence interval [CI]: 2.1-4.9) net higher maternal weight gain in the subsequent pregnancy. Relative to term births, preterm birth <32 weeks (+3.2 kg, 95% CI: 1.9-4.6), 32-33 weeks (+1.8 kg, 95% CI: 0.7-2.8) and 34-36 weeks (+0.9 kg, 95% CI: 0.6-1.3) were associated with higher net weight gain. Having an infant with severe neonatal morbidity was associated with a +1.2 kg (95% CI: 0.3-2.1) weight gain. Likewise, the aOR of moving to a higher BMI category was 1.27 (95% CI, 1.14-1.42) following a perinatal death, 1.21 (95% CI: 1.04-1.41) after a preterm birth <32 weeks, and 1.11 (95% CI: 1.02-1.22) with severe neonatal morbidity. CONCLUSION: Greater interpregnancy weight gain, and movement to a higher BMI category, are each more likely in a woman whose first-born was affected by certain major adverse perinatal events.

Maternal disability and initiation and duration of breastfeeding: analysis of a Canadian cross-sectional survey.

BACKGROUND: The World Health Organization recommends breastfeeding as the best method for infant feeding. Known risk factors for breastfeeding non-initiation and early cessation of breastfeeding are diverse and include low breastfeeding self-efficacy, poverty, smoking, obesity, and chronic illness. Although women with disabilities experience elevated rates of these risk factors, few studies have examined their breastfeeding outcomes. Our objective was to examine breastfeeding non-initiation and early cessation of breastfeeding in women with and without disabilities. METHODS: We used data from the 2017-2018 Canadian Community Health Survey. Included were n = 4,817 women aged 15-55 years who had a birth in the last five years, of whom 26.6% had a disability, ascertained using the Washington Group Short Set on Functioning. Prevalence ratios (aPR) of breastfeeding non-initiation, and of early cessation of any and exclusive breastfeeding before 6 months, were calculated for women with versus without disabilities. We also examined disability by severity (moderate/severe and mild, separately) and number of action domains impacted (≥ 2 and 1, separately). The main multivariable models were adjusted for maternal age, marital status, level of education, annual household income level, and immigrant status. RESULTS: There were no differences between women with and without disabilities in breastfeeding non-initiation (9.6% vs. 8.9%; aPR 0.88, 95% CI 0.63, 1.23). Women with disabilities were more likely to have early cessation of any (44.4% vs. 35.7%) and exclusive breastfeeding before 6 months (66.9% vs. 61.3%), with some attenuation in risk after adjustment for sociodemographic factors (aRR 1.15, 95% CI 0.99, 1.33 and aRR 1.07, 95% 0.98, 1.16, respectively). Disparities were larger for women with moderate/severe disabilities and disabilities in ≥ 2 domains, with differences attenuated by adjustment for socio-demographics. CONCLUSIONS: Women with disabilities, and particularly those with moderate/severe and multiple disabilities, could benefit from tailored, accessible breastfeeding supports that attend to the social determinants of health.

Neonatal outcomes of pregnant women attending integrated and standard substance use treatment programs in Ontario, Canada.

BACKGROUND: Substance use in pregnancy raises concern given its potential teratogenic effects. Given the unique needs of parenting people and the potential impact for developing children, specialized substance use treatment programs are increasingly being implemented for this population. Substance use treatment is associated with more positive neonatal outcomes compared with no treatment, however treatment models vary limiting our understanding of key treatment components/modelsFew studies have explored the influence of treatment model type (i.e., integrated treatments designed for pregnant clients compared with standard treatment models) and no studies have examined the influence of treatment model on neonatal outcomes using Canadian data. METHOD: We conducted a population-based cohort study of clients who were pregnant when initiating integrated (n = 564) and standard (n = 320) substance use treatment programs in Ontario, Canada. RESULTS: Neonatal outcomes did not significantly differ by treatment type (integrated or standard), with rates of adverse neonatal outcomes higher than published rates for the general population, despite receipt of adequate levels of prenatal care. While this suggests no significant impact of treatment, it is notable that as a group, clients engaged in integrated treatment presented with more risk factors for adverse neonatal outcomes than those in standard treatment. While we controlled for these risks in our analyses, this may have obscured their influence in relation to treatment type. CONCLUSION: Findings underscore the need for more nuanced research that considers the influence of client factors in interaction with treatment type. Pregnant clients engaged in any form of substance use treatment are at higher risk of having children who experience adverse neonatal outcomes. This underscores the urgent need for further investment in services and research to support maternal and neonatal health before and during pregnancy, as well as long-term service models that support women and children beyond the perinatal and early childhood periods.

Late preterm birth and growth trajectories during childhood: a linked retrospective cohort study.

BACKGROUND: Evidence suggests that accelerated postnatal growth in children is detrimental for adult cardiovascular health. It is unclear whether children born late preterm (34-36 weeks) compared to full term (≥ 39 weeks), have different growth trajectories. Our objective was to evaluate the association between gestational age groups and growth trajectories of children born between 2006-2014 and followed to 2021 in Ontario, Canada. METHODS: We conducted a retrospective cohort study of children from singleton births in TARGet Kids! primary care network with repeated measures of weight and height/length from birth to 14 years, who were linked to health administrative databases. Piecewise linear mixed models were used to model weight (kg/month) and height (cm/month) trajectories with knots at 3, 12, and 84 months. Analyses were conducted based on chronological age. RESULTS: There were 4423 children included with a mean of 11 weight and height measures per child. The mean age at the last visit was 5.9 years (Standard Deviation: 3.1). Generally, the more preterm, the lower the mean value of weight and height until early adolescence. Differences in mean weight and height for very/moderate preterm and late preterm compared to full term were evident until 12 months of age. Weight trajectories were similar between children born late preterm and full term with small differences from 84-168 months (mean difference (MD) -0.04 kg/month, 95% CI -0.06, -0.03). Children born late preterm had faster height gain from 0-3 months (MD 0.70 cm/month, 95% CI 0.42, 0.97) and 3-12 months (MD 0.17 cm/month, 95% CI 0.11, 0.22). CONCLUSIONS: Compared to full term, children born late preterm had lower average weight and height from birth to 14 years, had a slightly slower rate of weight gain after 84 months and a faster rate of height gain from 0-12 months. Follow-up is needed to determine if growth differences are associated with long-term disease risk.

Validation of Parent-reported Gestational Age Categories for Children Less Than 6 Years of Age.

BACKGROUND: Preterm birth is an important outcome or exposure in epidemiologic research. When administrative data on measured gestational age is not available, parent-reported gestational age can be obtained from questionnaires, which is subject to potential bias. To our knowledge, few studies have assessed the validity of parent-reported gestational age categories, including commonly defined categories of preterm birth. METHODS: We used linked data from primarily healthy children <6 years of age in TARGet Kids! in Toronto, Canada, and ICES administrative healthcare data from April 2011 to March 2020. We assessed the criterion validity of questionnaire-based parent-reported gestational age by calculating sensitivity and specificity for term (≥37 weeks), late preterm (34-36 weeks), and moderately preterm (32-33 weeks) gestational age categories, using administrative healthcare records of gestational age as the criterion standard. We conducted subgroup analyses for various parent and socioeconomic factors that may influence recall. RESULTS: Of the 4684 participants, 97.3% correctly classified the gestational age category according to administrative healthcare data. Parent-reported gestational age sensitivity ranged from 83.7% to 98.5% and specificity ranged from 88.3% to 99.8%, depending on category. For each subgroup characteristic, sensitivity and specificity were all ≥70%. Lower educational attainment, lower family income, father reporting, ≥1 year since birth, ≥2 children, lower parent age, and reported gestational diabetes and/or hypertension were associated with slightly lower sensitivity and/or specificity. CONCLUSIONS: In this linked cohort, parent-reported gestational age categories had high accuracy. Criterion validity varied minimally among some parent and socioeconomic factors. Our findings can inform future quantitative bias analyses.

Comparison of Emergency Department Use Between Pregnant People With and Without Disabilities in Ontario, Canada.

Importance: Emergency department (ED) use in pregnancy is common and occurs for a variety of reasons, including obstetrical complications, exacerbated underlying conditions, and inadequate outpatient health care access. People with disabilities have elevated rates of certain medical, psychiatric, and obstetrical conditions as well as inadequate access to prenatal care; their risk of ED use in pregnancy is not known, however. Objective: To compare the risk of ED use in pregnancy among people with physical, sensory, and intellectual or developmental disabilities with those without disabilities. Design, Setting, and Participants: Population-based cohort study leveraging linked administrative health data sets in Ontario, Canada, April 2003 to March 2019. Analysis included all recognized pregnancies to people with a preexisting physical, sensory, intellectual or developmental, or 2 or more (multiple) disabilities, and those without a disability. Data were analyzed from May 2022 to January 2023. Exposure: Disability was ascertained using algorithms applied to 2 or more outpatient physician visits or 1 or more ED visits or hospitalizations before conception. Main outcomes and measures: Modified Poisson regression-generated adjusted relative risks (aRR) and 95% CIs for any ED visit in pregnancy, from the estimated conception date up to the end of the pregnancy, adjusted for age, parity, income quintile, rurality, immigrant status, and preexisting chronic conditions, mental illness, and substance use disorders. Results: The cohort included 2 659 895 pregnant people with physical (221 739 participants; mean [SD] age, 29.8 [6.1] years), sensory (71 891 participants; mean [SD] age, 29.1 [6.4] years), intellectual or developmental (3877 participants; mean [SD] age, 26.1 [6.7] years), and multiple disabilities (14 359 participants; mean [SD] age, 29.5 [6.5] years), and pregnant people without a disability (2 348 023 participants; mean [SD] age, 29.4 [5.9] years). The rate of ED visits in pregnancy was 25.4% in people without a disability (596 771 visits). Relative to these individuals, the aRR for ED use was elevated in people with physical (aRR, 1.26; 95% CI, 1.25-1.27), sensory (aRR, 1.15; 95% CI, 1.14-1.17), intellectual or developmental (aRR, 1.33; 95% CI, 1.28-1.38), and multiple disabilities (aRR, 1.43; 95% CI, 1.40-1.46). Conclusions and Relevance: In this population-based study, people with disabilities were at elevated risk of ED use in pregnancy. This finding underscores the need for research on the benefits of proactive strategies to manage preexisting conditions in these individuals, improve their access to outpatient obstetrical and medical care, and prepare them for when ED visits occur.

Self-Harm Events and Suicide Deaths Among Autistic Individuals in Ontario, Canada.

Importance: Reasons for elevated suicide risks among autistic people are unclear, with insufficient population-based research on sex-specific patterns to inform tailored prevention and intervention. Objectives: To examine sex-stratified rates of self-harm events and suicide death among autistic individuals compared with nonautistic individuals, as well as the associated sociodemographic and clinical risk factors. Design, Setting, and Participants: This population-based matched-cohort study using linked health administrative databases in Ontario, Canada included all individuals with physician-recorded autism diagnoses from April 1, 1988, to March 31, 2018, each matched on age and sex to 4 nonautistic individuals from the general population. Self-harm events resulting in emergency health care from April 1, 2005, to December 31, 2020, were examined for one cohort, and death by suicide and other causes from April 1, 1993, to December 31, 2018, were examined for another cohort. Statistical analyses were conducted between October 2021 and June 2023. Exposure: Physician-recorded autism diagnoses from 1988 to 2018 from health administrative databases. Main Outcomes and Measures: Autistic and nonautistic individuals who were sex stratified a priori were compared using Andersen-Gill recurrent event models on self-harm events, and cause-specific competing risk models on death by suicide or other causes. Neighborhood-level income and rurality indices, and individual-level broad diagnostic categories of intellectual disabilities, mood and anxiety disorders, schizophrenia spectrum disorders, substance use disorders, and personality disorders were covariates. Results: For self-harm events (cohort, 379 630 individuals; median age at maximum follow-up, 20 years [IQR, 15-28 years]; median age of first autism diagnosis claim for autistic individuals, 9 years [IQR, 4-15 years]; 19 800 autistic females, 56 126 autistic males 79 200 nonautistic females, and 224 504 nonautistic males), among both sexes, autism diagnoses had independent associations with self-harm events (females: relative rate, 1.83; 95% CI, 1.61-2.08; males: relative rate, 1.47; 95% CI, 1.28-1.69) after accounting for income, rurality, intellectual disabilities, and psychiatric diagnoses. For suicide death (cohort, 334 690 individuals; median age at maximum follow-up, 19 years [IQR, 14-27 years]; median age of first autism diagnosis claim for autistic individuals, 10 years [IQR, 5-16 years]; 17 982 autistic females, 48 956 autistic males, 71 928 nonautistic females, 195 824 nonautistic males), there was a significantly higher crude hazard ratio among autistic females (1.98; 95% CI, 1.11-3.56) and a nonsignificantly higher crude hazard ratio among autistic males (1.34; 95% CI, 0.99-1.82); the increased risks were associated with psychiatric diagnoses. Conclusions and Relevance: This cohort study suggests that autistic individuals experienced increased risks of self-harm events and suicide death. Psychiatric diagnoses were significantly associated with the increased risks among both sexes, especially for suicide death, and in partially sex-unique ways. Autism-tailored and autism-informed clinical and social support to reduce suicide risks should consider multifactorial mechanisms, with a particular focus on the prevention and timely treatment of psychiatric illnesses.

Bilateral salpingo-oophorectomy at the time of benign hysterectomy among females with disabilities: a population-based cross-sectional study.

BACKGROUND: Up to 40% of patients aged ≤55 years undergo concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy, with practice variation in bilateral salpingo-oophorectomy occurring along the lines of patient health and social factors. Disability is common in premenopausal women and is an important determinant of reproductive health more broadly; however, studies on bilateral salpingo-oophorectomy rates among women with disabilities are lacking. OBJECTIVE: This study aimed to examine whether the use of concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy differs by preexisting disability status in adult females aged ≤55 years. STUDY DESIGN: This population-based cross-sectional study used data from the 2016-2019 US National Inpatient Sample. Females undergoing inpatient hysterectomy for a benign gynecologic indication (n=74,315) were classified as having physical (6.1%), sensory (0.1%), intellectual or developmental (0.2%), or multiple (0.2%) disabilities and compared with those without a disability. Logistic regression was used to estimate risk ratios for differences in bilateral salpingo-oophorectomy rates by disability status, adjusted for patient and clinical factors. Models were stratified by potentially avoidable or potentially appropriate bilateral salpingo-oophorectomy based on the presence of clinical indications for ovarian removal and by age group. RESULTS: Bilateral salpingo-oophorectomy at the time of benign hysterectomy occurred in 26.0% of females without a disability, with rates clearly elevated in those with a physical (33.2%; adjusted risk ratio, 1.10; 95% confidence interval, 1.05-1.14) or intellectual or developmental (31.1%; adjusted risk ratio, 1.32; 95% confidence interval, 1.02-1.64) disability, possibly elevated in those with multiple disabilities (38.2%; adjusted risk ratio, 1.20; 95% confidence interval, 0.94-1.45), and similar in those with a sensory disability (31.2%; adjusted risk ratio, 0.98; 95% confidence interval, 0.83-1.13). The results were similar but with lower statistical precision for potentially avoidable and potentially appropriate bilateral salpingo-oophorectomy, which occurred in 9.1% and 17.0% of females without a disability, respectively. The largest differences in bilateral salpingo-oophorectomy rates among women with any disability were observed in the perimenopausal 45- to 49-year age group. CONCLUSION: Females with disabilities experienced elevated concomitant bilateral salpingo-oophorectomy rates at the time of benign hysterectomy, particularly those with an intellectual or developmental disability and those of perimenopausal age, although some estimates were imprecise. Equity-focused physician training in surgical counseling and research into the epidemiology and experiences of gynecologic conditions among females with a disability may be beneficial.

Mental Illness Following Physical Assault Among Children.

Importance: Physical assault during childhood is common and can lead to lasting mental health problems. Yet, there are few studies on the patterns of mental illness (ie, timing of onset, type, and acuity) in survivors of physical assault. Objective: To determine the risk of incident health record diagnoses of mental illness among children who experienced assault compared with children who did not. Design, Setting, and Participants: This population-based matched cohort study used linked health administrative data sets in Ontario, Canada. Children aged 0 to 13 years who experienced an incident physical assault between 2006 and 2014 were age-matched (1:4) to children who had not experienced assault and followed up for a minimum of 5 years. Data were analyzed from January 2020 to March 2022. Exposure: Physical assault resulting in hospitalization or an emergency department (ED) visit between the ages of 0 and 13 years. Main Outcomes and Measures: The primary outcome was incident health record diagnosis of mental illness measured as any physician or hospital mental health care use or completed suicide. Secondary outcome measures included the acuity of incident mental illness and mental illness diagnostic category. Cox proportional hazards regression analysis generated hazard ratios (HR) for incident mental illness. Results: A total of 21 948 children unexposed to assault and 5487 exposed to assault were included in the study with a mean (SD) age of 7.0 (4.6) years. There were more boys in the group that experienced assault (3006 individuals [54.8%]) compared with the group who did not (9909 individuals [45.1%]). Compared with children unexposed to assault, those exposed were more likely to be in the highest deprivation index quintile (standardized difference, 0.21) and live in rural areas (standardized difference, 0.48). Their mothers more often had active mental illness (standardized difference, 0.35). More than one-third of the exposed children had a health record diagnosis of mental illness (2219 children [38.6%]; incidence rate (IR), 53.3 per 1000 person-years) compared with 23.4% (5130 children; IR, 32.2 per 1000 person-years) of unexposed children, with an overall adjusted hazard ratio (aHR) of 1.96 (95% CI, 1.85-2.08). The greatest risk was observed in the first year following the assault (aHR, 3.08; 95% CI, 2.68-3.54). In both groups, nonpsychotic disorders were the most common type of mental illness. Initial mental illness diagnoses occurred in an acute care setting for 14.0% of exposed children (769 children) vs 2.8% of unexposed children (609 children). Conclusions and Relevance: In this population-based matched cohort study, children who experienced assault had, on average, a 2 times higher risk of receiving a mental illness diagnosis and were more likely than children who had not experienced assault to present to acute care for mental illness. Early intervention to support mental health of assaulted children is warranted, particularly in the first year following assault.