Development and validation of the Cannabis Exposure in Pregnancy Tool (CEPT): a mixed methods study.

BACKGROUND: Evidence of associations between prenatal cannabis use (PCU) and maternal and infant health outcomes remains conflicting amid broad legalization of cannabis across Canada and 40 American states. A critical limitation of existing evidence lies in the non-standardized and crude measurement of prenatal cannabis use (PCU), resulting in high risk of misclassification bias. We developed a standardized tool to comprehensively measure prenatal cannabis use in pregnant populations for research purposes. METHODS: We conducted a mixed-methods, patient-oriented tool development and validation study, using a bias-minimizing process. Following an environmental scan and critical appraisal of existing prenatal substance use tools, we recruited pregnant participants via targeted social media advertising and obstetric clinics in Alberta, Canada. We conducted individual in-depth interviews and cognitive interviewing in separate sub-samples, to develop and refine our tool. We assessed convergent and discriminant validity internal consistency and 3-month test-retest reliability, and validated the tool externally against urine-THC bioassays. RESULTS: Two hundred fifty four pregnant women participated. The 9-item Cannabis Exposure in Pregnancy Tool (CEPT) had excellent discriminant (Cohen's kappa = -0.27-0.15) and convergent (Cohen's kappa = 0.72-1.0) validity; as well as high internal consistency (Chronbach's alpha = 0.92), and very good test-retest reliability (weighted Kappa = 0.92, 95% C.I. [0.86-0.97]). The CEPT is valid against urine THC bioassay (sensitivity = 100%, specificity = 82%). CONCLUSION: The CEPT is a novel, valid and reliable measure of frequency, timing, dose, and mode of PCU, in a contemporary sample of pregnant women. Using CEPT (compared to non-standardized tools) can improve measurement accuracy, and thus the quality of research examining PCU and maternal and child health outcomes.

Investigating associations between maternal stress, smoking and adverse birth outcomes: evidence from the All Our Families cohort.

BACKGROUND: Independently, active maternal and environmental tobacco smoke exposure and maternal stress have been linked to an increased risk of preterm birth and low birth weight. An understudied relationship is the potential for interactive effects between these risk factors. METHODS: Data was obtained from the All Our Families cohort, a study of 3,388 pregnant women < 25 weeks gestation recruited from those receiving prenatal care in Calgary, Canada between May 2008 and December 2010. We investigated the joint effects of active maternal smoking, total smoke exposure (active maternal smoking plus environmental tobacco smoke) and prenatal stress (Perceived Stress Scale, Spielberger State-Trait Anxiety Inventory), measured at two time points (< 25 weeks and 34-36 weeks gestation), on preterm birth and low birth weight. RESULTS: A marginally significant association was observed with the interaction active maternal smoking and Spielberger State-Trait Anxiety Inventory scores in relation to low birth weight, after imputation (aOR = 1.02, 95%CI: 1.00-1.03, p = 0.06). No significant joint effects of maternal stress and either active maternal smoking or total smoke exposure with preterm birth were observed. Active maternal smoking, total smoke exposure, Perceived Stress Scores, and Spielberger State-Trait Anxiety Inventory scores were independently associated with preterm birth and/or low birth weight. CONCLUSIONS: Findings indicate the role of independent effects of smoking and stress in terms of preterm birth and low birthweight. However, the etiology of preterm birth and low birth weight is complex and multifactorial. Further investigations of potential interactive effects may be useful in helping to identify women experiencing vulnerability and inform the development of targeted interventions.

Small for gestational age preterm infants and later adiposity and height: A systematic review and meta-analysis.

BACKGROUND: Overweight and obesity and their consequent morbidities are important worldwide health problems. Some research suggests excess adiposity origins may begin in fetal life, but unknown is whether this applies to infants born preterm. OBJECTIVE: The objective of the study was to assess the association between small for gestational age (SGA) birth and later adiposity and height among those born preterm. DATA SOURCES: MEDLINE, EMBASE and CINAHL until October 2022. STUDY SELECTION AND DATA EXTRACTION: Studies were included if they reported anthropometric (adiposity measures and height) outcomes for participants born preterm with SGA versus non-SGA. Screening, data extraction and risks of bias assessments were conducted in duplicate by two reviewers. SYNTHESIS: We meta-analysed across studies using random-effects models and explored potential heterogeneity sources. RESULTS: Thirty-nine studies met the inclusion criteria. In later life, preterm SGA infants had a lower body mass index (-0.66 kg/m2 , 95% CI -0.79, -0.53; 32 studies, I2 = 16.7, n = 30,346), waist circumference (-1.20 cm, 95% CI -2.17, -0.23; 13 studies, I2 = 19.4, n = 2061), lean mass (-2.62 kg, 95% CI -3.45, 1.80; 7 studies, I2 = 0, n = 205) and height (-3.85 cm, 95% CI -4.73, -2.96; 26 studies, I2 = 52.6, n = 4174) compared with those preterm infants born non-SGA. There were no differences between preterm SGA and preterm non-SGA groups in waist/hip ratio, body fat, body fat per cent, truncal fat per cent, fat mass index or lean mass index, although power was limited for some analyses. Studies were rated at high risk of bias due to potential residual confounding and low risk of bias in other domains. CONCLUSIONS: Compared to their preterm non-SGA peers, preterm infants born SGA have lower BMI, waist circumference, lean body mass and height in later life. No differences in adiposity were observed between SGA preterm infants and non-SGA preterm infants.

Association of Assisted Reproductive Technology With Offspring Growth and Adiposity From Infancy to Early Adulthood.

Importance: People conceived using assisted reproductive technology (ART) make up an increasing proportion of the world's population. Objective: To investigate the association of ART conception with offspring growth and adiposity from infancy to early adulthood in a large multicohort study. Design, Setting, and Participants: This cohort study used a prespecified coordinated analysis across 26 European, Asia-Pacific, and North American population-based cohort studies that included people born between 1984 and 2018, with mean ages at assessment of growth and adiposity outcomes from 0.6 months to 27.4 years. Data were analyzed between November 2019 and February 2022. Exposures: Conception by ART (mostly in vitro fertilization, intracytoplasmic sperm injection, and embryo transfer) vs natural conception (NC; without any medically assisted reproduction). Main Outcomes and Measures: The main outcomes were length / height, weight, and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared). Each cohort was analyzed separately with adjustment for maternal BMI, age, smoking, education, parity, and ethnicity and offspring sex and age. Results were combined in random effects meta-analysis for 13 age groups. Results: Up to 158 066 offspring (4329 conceived by ART) were included in each age-group meta-analysis, with between 47.6% to 60.6% females in each cohort. Compared with offspring who were NC, offspring conceived via ART were shorter, lighter, and thinner from infancy to early adolescence, with differences largest at the youngest ages and attenuating with older child age. For example, adjusted mean differences in offspring weight were -0.27 (95% CI, -0.39 to -0.16) SD units at age younger than 3 months, -0.16 (95% CI, -0.22 to -0.09) SD units at age 17 to 23 months, -0.07 (95% CI, -0.10 to -0.04) SD units at age 6 to 9 years, and -0.02 (95% CI, -0.15 to 0.12) SD units at age 14 to 17 years. Smaller offspring size was limited to individuals conceived by fresh but not frozen embryo transfer compared with those who were NC (eg, difference in weight at age 4 to 5 years was -0.14 [95% CI, -0.20 to -0.07] SD units for fresh embryo transfer vs NC and 0.00 [95% CI, -0.15 to 0.15] SD units for frozen embryo transfer vs NC). More marked differences were seen for body fat measurements, and there was imprecise evidence that offspring conceived by ART developed greater adiposity by early adulthood (eg, ART vs NC difference in fat mass index at age older than 17 years: 0.23 [95% CI, -0.04 to 0.50] SD units). Conclusions and Relevance: These findings suggest that people conceiving or conceived by ART can be reassured that differences in early growth and adiposity are small and no longer evident by late adolescence.

Impact of switching from digital mammography to tomosynthesis plus digital mammography on breast cancer screening in Alberta, Canada.

OBJECTIVES: To compare abnormal call rates (ACR), cancer detection rates (CDR), positive predictive values (PPVs), and annual return to screen recommendations after switching from digital mammography (DM) to digital breast tomosynthesis plus DM (DBT + DM) for breast cancer screening. SETTING: The Alberta Breast Cancer Screening Program collects screening data from clinics throughout the province of Alberta, Canada. METHODS: This study retrospectively collected data, between 2015 and 2018, on women aged 40+ who underwent breast cancer screening at two large volume multisite radiology groups to compare metrics one year prior and one year after DBT + DM implementation. Comparisons between modalities were carried out within age groups, within breast density categories, and for initial vs. subsequent screens. RESULTS: A total of 125,432 DM and 128,912 DBT + DM screening exams were performed. For women aged 50-74, the DBT + DM group had a higher ACR (p < 0.01) but lower annual return to screens (p < 0.01). CDR was higher post-DBT + DM implementation for women with scattered (6.0 per 1000 vs. 4.4 per 1000; p = 0.001) or heterogeneously dense breasts (6.5 per 1000 vs. 4.2 per 1000; p < 0.001). PPV was higher with DBT + DM for all age groups, with women 50-74 having a PPV of 8.3% using DBT + DM vs. 7.1% with DM (p = 0.009). CONCLUSION: All metrics improved or stayed the same after switching to DBT + DM except for ACR. However, the increase in ACR could be attributed to a trend already occurring prior to the switch. Longer term monitoring is needed to confirm these findings.

Opportunistic postpartum depression symptom screening at well-child clinics in Alberta, 2012-2016.

OBJECTIVES: The study objective was to assess the reach and delivery of opportunistic postpartum depression (PPD) symptom screening at well-child clinic (WCC) immunization appointments in Alberta. The relationship between socio-demographic factors and PPD symptom screening status, and PPD symptom scores was explored. METHOD: In this retrospective population-based cohort study, administrative health data from WCC immunization appointments were used to assess the PPD symptom screening delivery and scores from January 1, 2012 to December 31, 2016. The associations with maternal age and area-level material deprivation were determined by multivariable statistics. RESULTS: The number of births ranged from 51,537 to 55,787 annually. The percentage of mothers screened for PPD symptoms using the Edinburgh Postnatal Depression Scale decreased between 2012 and 2016, from 80.1% to 69.7%. Of those screened, 3-3.2% of the mothers were identified to be at high risk for PPD, annually. Screening status varied according to maternal age: mothers ≤29 years were more likely to be screened than mothers 30-34 years, while mothers ≥35 years were the least likely to be screened. Logistic regression analyses, adjusting for age, found the odds of not being screened increased with increases in area-level material deprivation. Language/cultural barriers were the most commonly reported reasons for not screening. CONCLUSION: Opportunistic PPD symptom screening at WCCs can be an efficient method to identify mothers who need postpartum support and to inform population-level public health surveillance. Additional work is needed to further understand barriers to PPD symptom screening, especially language, cultural, and socio-demographic factors.

RéSUMé: OBJECTIFS: Évaluer la portée et l'exécution du dépistage opportuniste des symptômes de dépression du post-partum (DPP) lors des visites d'immunisation en clinique du bien-être de l'enfant (CBEE) en Alberta. Nous avons exploré la relation entre les facteurs sociodémographiques et la situation à l'égard du dépistage des symptômes de DPP, ainsi que les pointages des symptômes de DPP. MéTHODE: Pour cette étude de cohorte populationnelle rétrospective, nous avons utilisé les données administratives sur la santé des visites d'immunisation en CBEE pour évaluer l'exécution et les pointages du dépistage des symptômes de DPP entre le 1er janvier 2012 et le 31 décembre 2016. Les associations avec l'âge maternel et la défavorisation matérielle régionale ont été déterminées par analyses statistiques multivariées. RéSULTATS: Le nombre de naissances variait entre 51 537 et 55 787 par année. Le pourcentage de mères dépistées pour les symptômes de DPP à l'aide de l'échelle de dépression postnatale d'Édimbourg a diminué sur la période de l'étude, passant de 80,1 % en 2012 à 69,7 % en 2016. Parmi les mères dépistées, 3 à 3,2 % par année ont été identifiées comme présentant un risque élevé de DPP. La situation à l'égard du dépistage variait selon l'âge maternel : les mères de 29 ans et moins étaient plus susceptibles d'être dépistées que celles de 30 à 34 ans, et les mères de 35 ans et plus étaient les moins susceptibles d'être dépistées. Des analyses de régression logistique, après ajustement pour tenir compte de l'âge, ont déterminé que la probabilité de ne pas être dépistée augmentait avec l'augmentation de la défavorisation matérielle régionale. Les barrières linguistiques ou culturelles ont été les raisons les plus communément citées de ne pas avoir réalisé de dépistage. CONCLUSION: Le dépistage opportuniste des symptômes de DPP dans les CBEE peut être un moyen efficace d'identifier les mères ayant besoin d'un soutien post-partum et d'orienter la surveillance de la santé publique à l'échelle de la population. D'autres études sont nécessaires pour mieux comprendre les barrières au dépistage des symptômes de DPP, en particulier les facteurs linguistiques, culturels et sociodémographiques.

Maximizing maternal health and value for money in postpartum depression screening: a cost-effectiveness analysis using the All Our Families cohort and administrative data in Alberta, Canada.

BACKGROUND: Postpartum depression (PPD) affects 10-15% of women, is costly and debilitating, yet often remains undiagnosed. Within Alberta, Canada, screening is conducted at public health well child clinics using the Edinburgh Postnatal Depression Scale. If screened high-risk, women are offered referral to their family physicians for follow up diagnosis and treatment. METHODS: We developed a decision tree to estimate the cost-effectiveness of PPD screening versus not screening in Alberta over a two-year time horizon using a public healthcare payer perspective. Both the current practice (51% attending referral) and a scenario analysis (100% attending referral) are presented. RESULTS: Current practice results suggest screening leads to an incremental cost-effectiveness ratio (ICER) of $17,644 USD per quality adjusted life year (QALY). At a population-level, this resulted in an annual 813 (11%) additional cases diagnosed, 120 additional QALYs gained, and an additional cost of $2.1 million relative to not screening. With 100% attending referral, the ICER fell to $13,908 per QALY, resulting in an annual 1997 (27%) additional cases diagnosed, 249 additional QALYs gained, and an additional cost of $3.5 million relative to not screening. LIMITATIONS: We were unable to explore the cost-effectiveness of PPD screening versus not screening for secondary populations, including children. CONCLUSIONS: The results suggest screening may be most valuable when participation and compliance are maximized, where all women screened high-risk attend referral. This leads to greater value for money and increased maternal health gains across the population. Collaboration among public health and primary care services is encouraged to improve outcomes.

Examining postpartum depression screening effectiveness in well child clinics in Alberta, Canada: A study using the All Our Families cohort and administrative data.

Affecting 10-15% of women, postpartum depression (PPD) can be debilitating and costly. While early identification has the potential to improve timely care, recommendations regarding the implementation of routine screening are inconsistent. In Alberta, screening is completed using the Edinburgh Postnatal Depression Scale during public health well child clinic visits. The objective of this study was to examine the effectiveness of screening in identifying, diagnosing and treating women at increased risk for PPD over the first year postpartum, compared to those unscreened. The All Our Families prospective pregnancy cohort was linked to public health, inpatient, outpatient, physician claims and community pharmaceutical data over the first year postpartum. Descriptive statistics and bivariate analyses examined differences in sample characteristics and PPD and non-PPD related utilization by screening category. Odds ratios and 95% confidence intervals for PPD diagnosis and mental health drugs dispensed were generated using crude and multivariable logistic regression models. Within our sample, 87% of the eligible population were screened, with 3% receiving a high-risk score, and 13% were unscreened. Compared to those unscreened, women screened high-risk had higher odds of being diagnosed with PPD (OR: 3.88, 95% CI: 2.18-6.92) and women screened low/moderate-risk had reduced odds of receiving a diagnosis (OR: 0.51, 95% CI: 0.35-0.74). High-risk women had an increased likelihood of diagnosis, higher PPD-related utilization and drugs dispensed compared to those unscreened. This information suggests that screening was effective at streamlining resources in Alberta. Future work should focus on evaluating the cost-effectiveness of PPD screening.

Maternal body mass index, gestational weight gain, and the risk of overweight and obesity across childhood: An individual participant data meta-analysis.

BACKGROUND: Maternal obesity and excessive gestational weight gain may have persistent effects on offspring fat development. However, it remains unclear whether these effects differ by severity of obesity, and whether these effects are restricted to the extremes of maternal body mass index (BMI) and gestational weight gain. We aimed to assess the separate and combined associations of maternal BMI and gestational weight gain with the risk of overweight/obesity throughout childhood, and their population impact. METHODS AND FINDINGS: We conducted an individual participant data meta-analysis of data from 162,129 mothers and their children from 37 pregnancy and birth cohort studies from Europe, North America, and Australia. We assessed the individual and combined associations of maternal pre-pregnancy BMI and gestational weight gain, both in clinical categories and across their full ranges, with the risks of overweight/obesity in early (2.0-5.0 years), mid (5.0-10.0 years) and late childhood (10.0-18.0 years), using multilevel binary logistic regression models with a random intercept at cohort level adjusted for maternal sociodemographic and lifestyle-related characteristics. We observed that higher maternal pre-pregnancy BMI and gestational weight gain both in clinical categories and across their full ranges were associated with higher risks of childhood overweight/obesity, with the strongest effects in late childhood (odds ratios [ORs] for overweight/obesity in early, mid, and late childhood, respectively: OR 1.66 [95% CI: 1.56, 1.78], OR 1.91 [95% CI: 1.85, 1.98], and OR 2.28 [95% CI: 2.08, 2.50] for maternal overweight; OR 2.43 [95% CI: 2.24, 2.64], OR 3.12 [95% CI: 2.98, 3.27], and OR 4.47 [95% CI: 3.99, 5.23] for maternal obesity; and OR 1.39 [95% CI: 1.30, 1.49], OR 1.55 [95% CI: 1.49, 1.60], and OR 1.72 [95% CI: 1.56, 1.91] for excessive gestational weight gain). The proportions of childhood overweight/obesity prevalence attributable to maternal overweight, maternal obesity, and excessive gestational weight gain ranged from 10.2% to 21.6%. Relative to the effect of maternal BMI, excessive gestational weight gain only slightly increased the risk of childhood overweight/obesity within each clinical BMI category (p-values for interactions of maternal BMI with gestational weight gain: p = 0.038, p < 0.001, and p = 0.637 in early, mid, and late childhood, respectively). Limitations of this study include the self-report of maternal BMI and gestational weight gain for some of the cohorts, and the potential of residual confounding. Also, as this study only included participants from Europe, North America, and Australia, results need to be interpreted with caution with respect to other populations. CONCLUSIONS: In this study, higher maternal pre-pregnancy BMI and gestational weight gain were associated with an increased risk of childhood overweight/obesity, with the strongest effects at later ages. The additional effect of gestational weight gain in women who are overweight or obese before pregnancy is small. Given the large population impact, future intervention trials aiming to reduce the prevalence of childhood overweight and obesity should focus on maternal weight status before pregnancy, in addition to weight gain during pregnancy.

Supporting healthy pregnancies: Examining variations in nutrition, weight management and substance abuse advice provision by prenatal care providers in Alberta, Canada. A study using the All Our Families cohort.

BACKGROUND: Pregnancy is a critical time for fetal development, and education of women regarding healthy lifestyle choices is an important function for prenatal care providers, those that provide care to women during pregnancy. Within Canada, women choose to receive pregnancy care from one of a variety of publicly funded care providers. This study examines the association between the type of care provider(s) seen during pregnancy and the provision of advice related to nutrition, weight management and substance abuse. METHODS: Using data from the Alberta-based All Our Families prospective pregnancy cohort, we conducted bivariate and multivariate analyses to determine the likelihood of receiving advice related to nutrition, weight management, and substance abuse across provider(s) seen. RESULTS: Of 3341 women in our sample, 38% saw a single provider during pregnancy and 56% received care from multiple providers. Advice on nutrition was more likely to be provided across all providers, while weight management and substance abuse was less frequently and less consistently discussed. Relative to doctors in low-risk maternity clinics, midwives were most likely to provide nutrition (OR: 3.09, 95% CI: 1.19-8.01) and weight management (OR: 1.99, 95% CI: 1.13-3.50) advice to women. CONCLUSION: Findings suggest that the type of prenatal advice received by women depends on the provider(s) seen during pregnancy. Substance abuse was least likely to be discussed across providers, suggesting important implications given recent cannabis legalization.

Gestational weight gain charts for different body mass index groups for women in Europe, North America, and Oceania.

BACKGROUND: Gestational weight gain differs according to pre-pregnancy body mass index and is related to the risks of adverse maternal and child health outcomes. Gestational weight gain charts for women in different pre-pregnancy body mass index groups enable identification of women and offspring at risk for adverse health outcomes. We aimed to construct gestational weight gain reference charts for underweight, normal weight, overweight, and grades 1, 2 and 3 obese women and to compare these charts with those obtained in women with uncomplicated term pregnancies. METHODS: We used individual participant data from 218,216 pregnant women participating in 33 cohorts from Europe, North America, and Oceania. Of these women, 9065 (4.2%), 148,697 (68.1%), 42,678 (19.6%), 13,084 (6.0%), 3597 (1.6%), and 1095 (0.5%) were underweight, normal weight, overweight, and grades 1, 2, and 3 obese women, respectively. A total of 138, 517 women from 26 cohorts had pregnancies with no hypertensive or diabetic disorders and with term deliveries of appropriate for gestational age at birth infants. Gestational weight gain charts for underweight, normal weight, overweight, and grade 1, 2, and 3 obese women were derived by the Box-Cox t method using the generalized additive model for location, scale, and shape. RESULTS: We observed that gestational weight gain strongly differed per maternal pre-pregnancy body mass index group. The median (interquartile range) gestational weight gain at 40 weeks was 14.2 kg (11.4-17.4) for underweight women, 14.5 kg (11.5-17.7) for normal weight women, 13.9 kg (10.1-17.9) for overweight women, and 11.2 kg (7.0-15.7), 8.7 kg (4.3-13.4) and 6.3 kg (1.9-11.1) for grades 1, 2, and 3 obese women, respectively. The rate of weight gain was lower in the first half than in the second half of pregnancy. No differences in the patterns of weight gain were observed between cohorts or countries. Similar weight gain patterns were observed in mothers without pregnancy complications. CONCLUSIONS: Gestational weight gain patterns are strongly related to pre-pregnancy body mass index. The derived charts can be used to assess gestational weight gain in etiological research and as a monitoring tool for weight gain during pregnancy in clinical practice.

Differential Associations of Adverse Childhood Experience on Maternal Health.

INTRODUCTION: The current study examined whether three distinct antecedent factors related to maternal adverse childhood experiences were differentially associated with maternal health and psychosocial outcomes in the antepartum period. It was hypothesized that all three adverse childhood experience factors would be positively associated with poor health prior to pregnancy, poor reproductive health history, and health complications and psychosocial difficulties during pregnancy. METHODS: Data from 1,994 women (mean age=30.87 years) and their infants were collected from a prospective longitudinal cohort from 2008 to 2011. Pregnant women completed self-report questionnaires and a healthcare professional assessed the mothers' health prior to pregnancy, reproductive history, and pregnancy complications. RESULTS: Data analyses were conducted from December 2016 to March 2017. Path analysis demonstrated that women who had experience with physical/emotional abuse in childhood were significantly more likely to enter pregnancy with a chronic health condition (AOR=1.25, 95% CI=1.02, 1.54) and to have psychosocial difficulties in their pregnancy (AOR=1.60, 95% CI=1.34, 1.89). Women who were exposed to household dysfunction in childhood were also significantly more likely to experience psychosocial difficulties during pregnancy (AOR=2.33, 95% CI=1.49, 3.65). There was no association between exposure to sexual abuse and maternal health or mental health outcomes. CONCLUSIONS: Adverse childhood experience categories differentially predicted maternal health and psychosocial outcomes prior to and during pregnancy. The overall variance accounted for by adverse childhood experiences was small (3%-19%), suggesting that factors other than childhood adversity likely contribute to maternal health.

Risk factors for delayed social-emotional development and behavior problems at age two: Results from the All Our Babies/Families (AOB/F) cohort.

BACKGROUND AND AIMS: Social-emotional delays and behavioral problems at preschool age are associated with negative outcomes at school age, including ongoing behavior problems, poorer social functioning, and academic difficulties. Understanding modifiable risk factors for suboptimal development requires consideration of contemporary family circumstances to determine areas for effective early intervention to optimize development. This study aimed to identify risk factors for delayed social-emotional development and behavior problems at age two among participants of the All Our Babies/Families cohort study. METHODS: Mothers (N = 1596) completed five comprehensive questionnaires spanning midpregnancy to 2 years postpartum. At child age two, behavior and competence outcomes were measured using the Brief Infant-Toddler Social and Emotional Assessment. Chi square analysis and multivariable logistic regression modeling was used to identify key risk factors for suboptimal child outcomes. Predicted probabilities for adverse outcomes in the presence of risk were calculated. RESULTS: Risk factors for possible delayed social-emotional development in children included maternal depression at 2 years postpartum (OR 2.46, 95% CI 1.63, 3.72), lower parenting self-efficacy at 2 years postpartum (OR 2.76, 95% CI 1.51, 5.06), non-daily play-based interaction when child was 1 and 2 years old (OR 1.43, 95% CI 1.02, 1.99), child delayed sleep initiation at 2 years of age (OR 1.58, 95% CI 1.05, 2.37), and playgroup non-attendance between 1 and 2 years postpartum (OR 1.43, 95% CI 1.03, 1.99). Risk factors for possible behavior problems included lower maternal optimism during pregnancy (OR 2.02, 95% CI 1.36, 2.99), maternal depression at 2 years postpartum (OR 2.19, 95% CI 1.46, 3.27), difficulty balancing responsibilities at 2 years postpartum (OR 2.32 95% CI 1.55, 3.47), child second language exposure at 2 years of age (OR 1.88, 95% CI 1.37, 2.58), child delayed sleep initiation at 2 years of age (OR 1.55 95% CI 1.06, 2.26), child frequent night wakings at 2 years of age (OR 2.95 95% CI 2.13, 4.10), and more screentime exposure at 2 years of age (OR 1.85 95% CI 1.34, 2.54). CONCLUSIONS: This study suggests that addressing maternal mental health and promoting parenting strategies that encourage play-based interaction, limiting screen time, preventing sleep problems, and engagement in informal playgroups would reduce the risk of behavior and social-emotional problems.

Timeliness and completeness of routine childhood vaccinations in children by two years of age in Alberta, Canada.

OBJECTIVES: Assessing timeliness and completeness of vaccine administration is important for evaluating the effectiveness of immunization programs. Few studies have reported timeliness, particularly in Canada. The objective of this study was to examine timeliness of the receipt of vaccination for each routine childhood recommended vaccine by 24 months of age among children in a community-based pregnancy cohort in Calgary, Alberta. METHODS: Survey data from a community-based pregnancy cohort in Alberta were linked to Public Health vaccination records of children (n = 2763). The proportion of children receiving early, timely, delayed, or no vaccination was calculated. A dose was considered early if it was administered before the recommended age in days as per the vaccination schedule, timely if administered at any time from start of recommended age in days to age in days when delay counts were initiated, and delayed if it was administered on or after age in days when delay counts were initiated. Series completion rates were also calculated. RESULTS: For multi-dose vaccines, over 80% of children had timely doses at 2, 4 and 6 months. By 12 months, this proportion decreased to 65% (95% CI: 63%-66%) for meningococcal conjugate group C, 61% (95% CI: 59%-62%) for measles antigen-containing vaccines and 64% (95% CI: 62%-65%) for varicella antigen-containing vaccines. At 18 months, only 55% (95% CI: 53%-56%) of the children had a timely 4th dose of diphtheria, acellular pertussis, tetanus, polio, and Haemophilus influenzae type b vaccine. Eventual series completion rate for all recommended vaccines was 77% (95% CI: 75%-79%). CONCLUSION: The timeliness and completeness of routine childhood vaccination in preschool children in this community-based pregnancy cohort is lower than provincial targets. Data on timeliness of vaccination can inform further work on barriers and enablers to vaccination in order to meet provincial targets.

Maternal perceptions of underweight and overweight for 6-8†years olds from a Canadian cohort: reporting weights, concerns and conversations with healthcare providers.

OBJECTIVES: The majority of mothers do not correctly identify their child's weight status. The reasons for the misperception are not well understood. This study's objective was to describe maternal perceptions of their child's body mass index (BMI) and maternal report of weight concerns raised by a health professional. DESIGN: Prospective, community-based cohort. PARTICIPANTS: Data were collected in 2010 from 450 mothers previously included in a longitudinal birth cohort. Mothers of children aged 6-8 years reported their child's anthropometric measures and were surveyed concerning their opinion about their child's weight. They were also asked if a healthcare provider raised any concerns regarding their child's body weight. Child BMI was categorised according to the WHO Growth Charts adapted for Canada. Descriptive statistics and bivariate analyses were used to evaluate mothers' ability to correctly identify their children's body habitus. RESULTS: 74% of children had a healthy BMI, 10% were underweight, 9% were overweight and 7% were obese. 80%, 89% and 62% of mothers with underweight, overweight and obese children, respectively, believed that their child was at the right weight. The proportion of mothers who recalled a health professional raising concerns about their child being underweight, overweight, and obese was low (12.5%). CONCLUSIONS: The majority of mothers with children at unhealthy weights misclassified and normalised their child's weight status, and they did not recall a health professional raising concerns regarding their child's weight. The highest rates of child body weight misclassification occurred in overweight children. This suggests that there are missed opportunities for healthcare professionals to improve knowledge exchange and early interventions to assist parents to recognise and support healthy weights for their children.

Maternal Whole Blood Gene Expression at 18 and 28 Weeks of Gestation Associated with Spontaneous Preterm Birth in Asymptomatic Women.

The heterogeneity of spontaneous preterm birth (SPTB) requires an interdisciplinary approach to determine potential predictive risk factors of early delivery. The aim of this study was to investigate maternal whole blood gene expression profiles associated with spontaneous preterm birth (SPTB, <37 weeks) in asymptomatic pregnant women. The study population was a matched subgroup of women (51 SPTBs, 114 term delivery controls) who participated in the All Our Babies community based cohort in Calgary (n = 1878). Maternal blood at 17-23 (sampling time point 1, T1) and 27-33 weeks of gestation (T2) were collected. Total RNA was extracted and microarray was performed on 326 samples (165 women). Univariate analyses determined significant clinical factors and differential gene expression associated with SPTB. Thirteen genes were validated using qRT-PCR. Three multivariate logistic models were constructed to identify gene expression at T1 (Model A), T2 (Model B), and gene expression fold change from T1 to T2 (Model C) associated with SPTB. All models were adjusted for clinical factors. Model C can predict SPTB with 65% sensitivity and 88% specificity in asymptomatic women after adjusting for history of abortion and anaemia (occurring before T2). Clinical data enhanced the sensitivity of the Models to predict SPTB. In conclusion, clinical factors and whole blood gene expression are associated with SPTB in asymptomatic women. An effective screening tool for SPTB during pregnancy would enable targeted preventive approaches and personalised antenatal care.

The impact of caesarean section on breastfeeding initiation, duration and difficulties in the first four months postpartum.

BACKGROUND: The caesarean section (c-section) rate in Canada is 27.1%, well above the 5-15% of deliveries suggested by the World Health Organization in 2009. Emergency and planned c-sections may adversely affect breastfeeding initiation, milk supply and infant breastfeeding receptivity compared to vaginal deliveries. Our study examined mode of delivery and breastfeeding initiation, duration, and difficulties reported by mothers at 4 months postpartum. METHODS: The All Our Babies study is a prospective pregnancy cohort in Calgary, Alberta, that began in 2008. Participants completed questionnaires at <25 and 34-36 weeks gestation and approximately 4 months postpartum. Demographic, mental health, lifestyle, and health services data were obtained. Women giving birth to singleton infants were included (n = 3021). Breastfeeding rates and difficulties according to mode of birth (vaginal, planned c-section and emergency c-section) were compared using cross-tabulations and chi-square tests. A multivariable logistic regression model was created to examine the association between mode of birth on breastfeeding duration to 12 weeks postpartum. RESULTS: More women who delivered by planned c-section had no intention to breastfeed or did not initiate breastfeeding (7.4% and 4.3% respectively), when compared to women with vaginal births (3.4% and 1.8%, respectively) and emergency c-section (2.7% and 2.5%, respectively). Women who delivered by emergency c-section were found to have a higher proportion of breastfeeding difficulties (41%), and used more resources before (67%) and after (58%) leaving the hospital, when compared to vaginal delivery (29%, 40%, and 52%, respectively) or planned c-sections (33%, 49%, and 41%, respectively). Women who delivered with a planned c-section were more likely (OR = 1.61; 95% CI: 1.14, 2.26; p = 0.014) to discontinue breastfeeding before 12 weeks postpartum compared to those who delivered vaginally, controlling for income, education, parity, preterm birth, maternal physical and mental health, ethnicity and breastfeeding difficulties. CONCLUSIONS: We found that when controlling for socio-demographic and labor and delivery characteristics, planned c-section is associated with early breastfeeding cessation. Anticipatory guidance around breastfeeding could be provided to women considering a planned c-section. As well, additional supportive care could be made available to lactating women with emergency c-sections, within the first 24 hours post birth and throughout the early postpartum period.

Protective factors for child development at age 2 in the presence of poor maternal mental health: results from the All Our Babies (AOB) pregnancy cohort.

OBJECTIVE: To identify the combination of factors most protective of developmental delay at age 2 among children exposed to poor maternal mental health. DESIGN: Observational cohort study. SETTING: Pregnant women were recruited from primary healthcare offices, the public health laboratory service and community posters in Calgary, Alberta, Canada. PARTICIPANTS: 1596 mother-child dyads who participated in the All Our Babies study and who completed a follow-up questionnaire when their child was 2 years old. Among participants who completed the 2-year questionnaire and had complete mental health data (n=1146), 305 women (27%) were classified as high maternal mental health risk. PRIMARY MEASURES: Child development at age 2 was described and a resilience analysis was performed among a subgroup of families at maternal mental health risk. The primary outcome was child development problems. Protective factors were identified among families at risk, defined as maternal mental health risk, a composite measure created from participants' responses to mental health life course questions and standardised mental health measures. RESULTS: At age 2, 18% of children were classified as having development problems, 15% with behavioural problems and 13% with delayed social-emotional competencies. Among children living in a family with maternal mental health risk, protective factors against development problems included higher social support, higher optimism, more relationship happiness, less difficulty balancing work and family responsibilities, limiting the child's screen time to <1 hour per day and the child being able to fall asleep in <30 min and sleeping through the night by age 2. CONCLUSIONS: Among families where the mother has poor mental health, public health and early intervention strategies that support interpersonal relationships, social support, optimism, work-life balance, limiting children's screen time and establishing good sleep habits in the child's first 2 years show promise to positively influence early child development.

Pregnant Women's Perceptions of Harms and Benefits of Mental Health Screening.

BACKGROUND: A widely held concern of screening is that its psychological harms may outweigh the benefits of early detection and treatment. This study describes pregnant women's perceptions of possible harms and benefits of mental health screening and factors associated with identifying screening as harmful or beneficial. METHODS: This study analyzed a subgroup of women who had undergone formal or informal mental health screening from our larger multi-site, cross-sectional study. Pregnant women >16 years of age who spoke/read English were recruited (May-December 2013) from prenatal classes and maternity clinics in Alberta, Canada. Descriptive statistics were generated to summarize harms and benefits of screening and multivariable logistic regression identified factors associated with reporting at least one harm or affirming screening as a positive experience (January-December 2014). RESULTS: Overall study participation rate was 92% (N = 460/500). Among women screened for mental health concerns (n = 238), 63% viewed screening as positive, 69% were glad to be asked, and 87% took it as evidence their provider cared about them. Only one woman identified screening as a negative experience. Of the 6 harms, none was endorsed by >7% of women, with embarrassment being most cited. Women who were very comfortable (vs somewhat/not comfortable) with screening were more likely to report it as a positive experience. LIMITATIONS: Women were largely Caucasian, well-educated, partnered women; thus, findings may not be generalizable to women with socioeconomic risk. CONCLUSIONS: Most women perceived prenatal mental health screening as having high benefit and low harm. These findings dispel popular concerns that mental health screening is psychologically harmful.