Shared decision making in pregnancy in inflammatory bowel disease: design of a patient orientated decision aid.

BACKGROUND: Research has indicated a lack of disease-specific reproductive knowledge among patients with Inflammatory Bowel Disease (IBD) and this has been associated with increased "voluntary childlessness". Furthermore, a lack of knowledge may contribute to inappropriate medication changes during or after pregnancy. Decision aids have been shown to support decision making in pregnancy as well as in multiple other chronic diseases. A published decision aid for pregnancy in IBD has not been identified, despite the benefit of pre-conception counselling and patient desire for a decision support tool. This study aimed to develop and test the feasibility of a decision aid encompassing reproductive decisions in the setting of IBD. METHODS: The International Patient Decision Aid Standards were implemented in the development of the Pregnancy in IBD Decision Aid (PIDA). A multi-disciplinary steering committee was formed. Patient and clinician focus groups were conducted to explore themes of importance in the reproductive decision-making processes in IBD. A PIDA prototype was designed; patient interviews were conducted to obtain further insight into patient perspectives and to test the prototype for feasibility. RESULTS: Issues considered of importance to patients and clinicians encountering decisions regarding pregnancy in the setting of IBD included fertility, conception timing, inheritance, medications, infant health, impact of surgery, contraception, nutrition and breastfeeding. Emphasis was placed on the provision of preconception counselling early in the disease course. Decisions relating to conception and medications were chosen as the current focus of PIDA, however content inclusion was broad to support use across preconception, pregnancy and post-partum phases. Favourable and constructive user feedback was received. CONCLUSIONS: The novel development of a decision aid for use in pregnancy and IBD was supported by initial user testing.

Predictors of child resilience in a community-based cohort facing flood as natural disaster.

BACKGROUND: Natural disasters are unpredictable and uncontrollable events that usually induce significant level of stress and social disruption in afflicted individuals. The consequences are formidable, affecting lifetime health and economic prosperity. Among natural disasters, floods are the most common causes and tend to have the highest economic burden. The aim of this study was to examine factors associated with child resilience in the face of the natural disaster experienced by the city of Calgary, Alberta, Canada during its unprecedented flood of 2013. METHODS: The current study was conducted in a community-based cohort situated in the city of Calgary. The participants were recruited out of the All Our Families longitudinal cohort within the Cummings School of Medicine at the University of Calgary. Of the total 1711 people contacted, 469 people consented and completed questionnaire. Of those 469 who consented to be part of the study, 467 were eligible to be included for analysis. A flood impact questionnaire was delivered 6 months after the 2013 flood in families whose children were an average of 3 years old. Mother reported questionnaires were used to assess child resilience. The study included maternal data on a range of factors including socio-demographic, history of mental health, relationship with the partner and social support. Child related data were also incorporated into the study, and variables included delivery mode, child sex, and child age at the time of disaster. RESULTS: Child resilience was best predicted by mother's age and social support, and by child gender, the child's externalizing and internalizing behaviors and the Rothbart temperament scale: effortful control. Furthermore, this study revealed that children who were more exposed to the flood events, showed higher resilience compared to the children who were less or not exposed. CONCLUSIONS: These findings highlight the risk and protective factors that predict child resilience and suggest that mother reported questionnaire are useful tools to assess child resilience amidst early life adversity.

Adversity in childhood and depression in pregnancy.

Adverse childhood experiences (ACEs) have been found to be associated with various health conditions; however, there is dearth of evidence on the relationship between ACEs and prenatal depression. This study was conducted to determine the association between overall ACE score and prenatal depression symptoms, assess the moderating effect of social support and partner support on this relationship, and determine the association between individual ACE scores and prenatal depression. A secondary analysis was conducted of data from an RCT that assessed the feasibility of e-screening for maternal mental health among 636 pregnant women recruited from antenatal clinics. Two logistic regression models were built to reach our objectives. Over 80% of the participants were older than 25 years and had education beyond high school. Eighteen percent of the women had an ACE score of four or more. Univariable analysis found a 2.5-fold increase in the odds of prenatal depression for women with an ACEs score of ≥ 4. When examining the overall ACE score, lack of social support during pregnancy [AOR = 4.16; 95%CI (2.10-10.35)] and partner's relationship [AOR = 2.23; 95%CI (1.12-4.44)] were associated with prenatal depression while among the individual ACE scores, living with a person who went to prison was found to be associated with prenatal depression even when controlled for all variables. No moderating effect was found. These findings suggest for the improvement of partner's relationship and provision of social support before women conceive, in order to mitigate the effect of these adversities.

Study protocol for a comparative effectiveness trial of two models of perinatal integrated psychosocial assessment: the PIPA project.

BACKGROUND: Studies examining psychosocial and depression assessment programs in maternity settings have not adequately considered the context in which psychosocial assessment occurs or how broader components of integrated care, including clinician decision-making aids, may optimise program delivery and its cost-effectiveness. There is also limited evidence relating to the diagnostic accuracy of symptom-based screening measures used in this context. The Perinatal Integrated Psychosocial Assessment (PIPA) Project was developed to address these knowledge gaps. The primary aims of the PIPA Project are to examine the clinical- and cost-effectiveness of two alternative models of integrated psychosocial care during pregnancy: 'care as usual' (the SAFE START model) and an alternative model (the PIPA model). The acceptability and perceived benefit of each model of care from the perspective of both pregnant women and their healthcare providers will also be assessed. Our secondary aim is to examine the psychometric properties of a number of symptom-based screening tools for depression and anxiety when used in pregnancy. METHODS: This is a comparative-effectiveness study comparing 'care as usual' to an alternative model sequentially over two 12-month periods. Data will be collected from women at Time 1 (initial antenatal psychosocial assessment), Time 2 (2-weeks after Time 1) and from clinicians at Time 3 for each condition. Primary aims will be evaluated using a between-groups design, and the secondary aim using a within group design. DISCUSSION: The PIPA Project will provide evidence relating to the clinical- and cost- effectiveness of psychosocial assessment integrated with electronic clinician decision making prompts, and referral options that are tailored to the woman's psychosocial risk, in the maternity care setting. It will also address research recommendations from the Australian (2011) and NICE (2015) Clinical Practice Guidelines. TRIAL REGISTRATION: ACTRN12617000932369.

Pregnant Women's Views on the Feasibility and Acceptability of Web-Based Mental Health E-Screening Versus Paper-Based Screening: A Randomized Controlled Trial.

BACKGROUND: Major international guidelines recommend mental health screening during the perinatal period. However, substantial barriers to screening have been reported by pregnant and postpartum women and perinatal care providers. E-screening offers benefits that may address implementation challenges. OBJECTIVE: The primary objective of this randomized controlled trial was to evaluate the feasibility and acceptability of Web-based mental health e-screening compared with paper-based screening among pregnant women. A secondary objective was to identify factors associated with women's preferences for e-screening and disclosure of mental health concerns. METHODS: Pregnant women recruited from community and hospital-based antenatal clinics and hospital-based prenatal classes were computer-randomized to a fully automated Web-based e-screening intervention group or a paper-based control group. Women were eligible if they spoke or read English, were willing to be randomized to e-screening, and were willing to participate in a follow-up diagnostic interview. The intervention group completed the Antenatal Psychosocial Health Assessment and the Edinburgh Postnatal Depression Scale on a tablet computer, while controls completed them on paper. All women completed self-report baseline questions and were telephoned 1 week after randomization by a blinded research assistant for a MINI International Neuropsychiatric Interview. Renker and Tonkin's tool of feasibility and acceptability of computerized screening was used to assess the feasibility and acceptability of e-screening compared with paper-based screening. Intention-to-treat analysis was used. To identify factors associated with preference for e-screening and disclosure, variables associated with each outcome at P<.20 were simultaneously entered into final multivariable models to estimate adjusted odds ratios (AORs) and 95% CIs. RESULTS: Of the 675 eligible women approached, 636 agreed to participate (participation rate 94.2%) and were randomized to the intervention (n=305) or control (n=331) groups. There were no significant baseline differences between groups. More women in the e-screening group strongly or somewhat agreed that they would like to use a tablet for answering questions on emotional health (57.9%, 175/302 vs 37.2%, 121/325) and would prefer using a tablet to paper (46.0%, 139/302 vs 29.2%, 95/325), compared with women in the paper-based screening group. There were no differences between groups in women's disclosure of emotional health concerns (94.1%, 284/302 vs 90.2%, 293/325). Women in the e-screening group consistently reported the features of e-screening more favorably than controls (more private or confidential, less impersonal, less time-consuming). In the multivariable models, being in the e-screening group was significantly associated with preferring e-screening (AOR 2.29, 95% CI 1.66-3.17), while no factors were significantly associated with disclosure. CONCLUSIONS: The findings suggest that mental health e-screening is feasible and acceptable to pregnant women. TRIAL REGISTRATION: Clinicaltrials.gov NCT01899534; https://clinicaltrials.gov/ct2/show/NCT01899534 (Archived by WebCite at http://www.webcitation.org/6ntWg1yWb).

Correlates of Abuse Around the Time of Pregnancy: Results from a National Survey of Canadian Women.

OBJECTIVES: Although several studies have examined risk factors associated with abuse during pregnancy or postpartum periods, many used clinic-based or small regional samples, and few were national or population-based, limiting their generalizability and clinical utility. The purpose of this study was to describe the correlates of abuse around the time of pregnancy among a nationally representative sample of women in Canada. METHODS: Using data from 6421 postpartum women (weighted n = 76,500) who completed the Canadian Maternity Experiences Survey from 10/2006 to 01/2007, we explored the association between demographic, psychosocial, behavioral, medical/obstetric factors and 'any' and 'severe' abuse. 'Any abuse' was defined as an affirmative answer to one or more of 10 items asked about physical or sexual abuse or threats of abuse. 'Severe abuse' was defined as experiencing a combination of threats and physical or sexual abuse. Odds ratios and their 95 % confidence intervals were generated from multivariable logistic regression models. RESULTS: 10.5 % of women (weighted n = 8400) reported 'any' abuse and 4.3 % (weighted n = 3400) reported 'severe' abuse in the previous 2 years. Correlates of severe abuse included: age <20 years; household income below the low income cut-off; single; stressful life events; history of depression or antidepressant use; smoking during pregnancy; and alcohol use prior to pregnancy. Correlates of 'any' abuse were the same as 'severe' abuse with the addition of age 20-34 years, developing a new health problem during pregnancy, and inadequate support during pregnancy. Increased odds of 'any' and 'severe' abuse were found for women who self-identified as Aboriginal and reduced odds of 'any' abuse were found among immigrant women and those who took folic acid pre-pregnancy. CONCLUSIONS: We identified risk factors that may enhance early detection of abuse in the perinatal period, and inform the development of interventions and preventive strategies to address this important public health problem.

Documentation of guideline adherence in antenatal records across maternal weight categories: a chart review.

BACKGROUND: Documentation in medical records fulfills key functions, including management of care, communication, quality assurance and record keeping. We sought to describe: 1) rates of standard prenatal care as documented in medical charts, and given the higher risks with excess weight, whether this documentation varied among normal weight, overweight and obese women; and 2) adherence to obesity guidelines for obese women as documented in the chart. METHODS: We conducted a chart review of 300 consecutive charts of women who delivered a live singleton at an academic tertiary centre from January to March 2012, computing Analysis of Variance and Chi Square tests. RESULTS: The proportion of completed fields on the mandatory antenatal forms varied from 100% (maternal age) to 52.7% (pre-pregnancy body mass index). Generally, documentation of care was similar across all weight categories for maternal and prenatal genetic screening tests, ranging from 54.0% (documentation of gonorrhea/chlamydia tests) to 85.0% (documentation of anatomy scan). Documentation of education topics varied widely, from fetal movement in almost all charts across all weight categories but discussion of preterm labour in only 20.6%, 12.7% and 13.4% of normal weight, overweight and obese women's charts (p = 0.224). Across all weight categories, documentation of discussion of exercise, breastfeeding and pain management occurred in less than a fifth of charts. CONCLUSION: Despite a predominance of excess weight in our region, as well as increasing perinatal risks with increasing maternal weight, weight-related issues and other elements of prenatal care were suboptimally documented across all maternal weight categories, despite an obesity guideline.

Public views of acceptability of perinatal mental health screening and treatment preference: a population based survey.

BACKGROUND: At a prevalence rate of 13-25%, mental health problems are among the most common morbidities of the prenatal and postnatal periods. They have been associated with increased risk of preterm birth and low birthweight, child developmental delay, and poor child mental health. However, very few pregnant and postpartum women proactively seek help or engage in treatment and less than 15% receive needed mental healthcare. While system-related barriers limit accessibility and availability of mental health services, personal barriers, such as views of mental health and its treatment, are also cited as significant deterrents of obtaining mental healthcare. The purposes of this population-based study were to identify the public's views regarding mental health screening and treatment in pregnant and postpartum women, and to determine factors associated with those views. METHODS: A computer-assisted telephone survey was conducted by the Population Research Laboratory with a random sample of adults in Alberta, Canada. Questions were drawn from the Perinatal Depression Monitor, an Australian population-based survey on perinatal mental health; additional questions were developed and tested to reflect the Canadian context. Interviews were conducted in English and were less than 30 minutes in duration. Descriptive and multivariable regression analyses were conducted. RESULTS: Among the 1207 respondents, 74.8% had post-secondary education, 16.3% were 18-34 years old, and two-thirds (66.1%) did not have children <18 years living at home. The majority of respondents strongly agreed/agreed that all women should be screened in the prenatal (63.0%) and postpartum periods (72.7%). Respondents reported that when seeking help and support their first choice would be a family doctor. Preferred treatments were talking to a doctor or midwife and counseling. Knowledge of perinatal mental health was the main factor associated with different treatment preferences. CONCLUSIONS: The high acceptability of universal perinatal mental health screening among the public provides a strong message regarding the public value for routine screening during pregnancy and postpartum periods. Perinatal mental health literacy is the most prominent determinant of screening and treatment acceptability and preference. Efforts to enhance population literacy as part of a multifaceted perinatal mental health strategy may optimize pregnant and postpartum women's mental health.

The Public's views of mental health in pregnant and postpartum women: a population-based study.

BACKGROUND: We used population-based data to determine the public's views of prenatal and postnatal mental health and to identify predictors of those views. METHODS: A computer-assisted telephone survey was conducted by the Population Health Laboratory (University of Alberta) with a random sample of participants from the province of Alberta, Canada. Respondents were eligible to participate if they were: 1) ≥18 years; and 2) contacted by direct dialing. Questions were drawn from the Perinatal Depression Monitor, an Australian population-based survey on perinatal mental health; additional questions were developed and tested to reflect the Canadian context. Descriptive and multivariable regression analyses were conducted. RESULTS: Among the 1207 respondents, 74.7% had post-secondary education, 16.3% were in childbearing years, and over half (57.4%) reported knowing a woman who had experienced postpartum depression. Significantly more respondents had high levels of knowledge of postnatal (87.4%) than prenatal (70.5%) mental health (p < .01). Only 26.6% of respondents accurately identified that prenatal anxiety/depression could negatively impact child development. Personal knowledge of a woman with postpartum depression was a significant predictor of prenatal and postnatal mental health knowledge. CONCLUSIONS: While the public's knowledge of postnatal mental health is high, knowledge regarding prenatal mental health and its influence on child development is limited. Strategies for improving perinatal mental health literacy should target these knowledge deficits.

Quality of prenatal care questionnaire: instrument development and testing.

BACKGROUND: Utilization indices exist to measure quantity of prenatal care, but currently there is no published instrument to assess quality of prenatal care. The purpose of this study was to develop and test a new instrument, the Quality of Prenatal Care Questionnaire (QPCQ). METHODS: Data for this instrument development study were collected in five Canadian cities. Items for the QPCQ were generated through interviews with 40 pregnant women and 40 health care providers and a review of prenatal care guidelines, followed by assessment of content validity and rating of importance of items. The preliminary 100-item QPCQ was administered to 422 postpartum women to conduct item reduction using exploratory factor analysis. The final 46-item version of the QPCQ was then administered to another 422 postpartum women to establish its construct validity, and internal consistency and test-retest reliability. RESULTS: Exploratory factor analysis reduced the QPCQ to 46 items, factored into 6 subscales, which subsequently were validated by confirmatory factor analysis. Construct validity was also demonstrated using a hypothesis testing approach; there was a significant positive association between women's ratings of the quality of prenatal care and their satisfaction with care (r = 0.81). Convergent validity was demonstrated by a significant positive correlation (r = 0.63) between the "Support and Respect" subscale of the QPCQ and the "Respectfulness/Emotional Support" subscale of the Prenatal Interpersonal Processes of Care instrument. The overall QPCQ had acceptable internal consistency reliability (Cronbach's alpha = 0.96), as did each of the subscales. The test-retest reliability result (Intra-class correlation coefficient = 0.88) indicated stability of the instrument on repeat administration approximately one week later. Temporal stability testing confirmed that women's ratings of their quality of prenatal care did not change as a result of giving birth or between the early postpartum period and 4 to 6 weeks postpartum. CONCLUSION: The QPCQ is a valid and reliable instrument that will be useful in future research as an outcome measure to compare quality of care across geographic regions, populations, and service delivery models, and to assess the relationship between quality of care and maternal and infant health outcomes.

Cumulative psychosocial stress, coping resources, and preterm birth.

Preterm birth constitutes a significant international public health issue, with implications for child and family well-being. High levels of psychosocial stress and negative affect before and during pregnancy are contributing factors to shortened gestation and preterm birth. We developed a cumulative psychosocial stress variable and examined its association with early delivery controlling for known preterm birth risk factors and confounding environmental variables. We further examined this association among subgroups of women with different levels of coping resources. Utilizing the All Our Babies (AOB) study, an ongoing prospective pregnancy cohort study in Alberta, Canada (n = 3,021), multinomial logistic regression was adopted to examine the independent effect of cumulative psychosocial stress and preterm birth subgroups compared to term births. Stratified analyses according to categories of perceived social support and optimism were undertaken to examine differential effects among subgroups of women. Cumulative psychosocial stress was a statistically significant risk factor for late preterm birth (OR = 1.73; 95 % CI = 1.07, 2.81), but not for early preterm birth (OR = 2.44; 95 % CI = 0.95, 6.32), controlling for income, history of preterm birth, pregnancy complications, reproductive history, and smoking in pregnancy. Stratified analyses showed that cumulative psychosocial stress was a significant risk factor for preterm birth at <37 weeks gestation for women with low levels of social support (OR = 2.09; 95 % CI = 1.07, 4.07) or optimism (OR = 1.87; 95 % CI = 1.04, 3.37). Our analyses suggest that early vulnerability combined with current anxiety symptoms in pregnancy confers risk for preterm birth. Coping resources may mitigate the effect of cumulative psychosocial stress on the risk for early delivery.

Prenatal and postnatal maternal mental health and school-age child development: a systematic review.

One in six children entering school experiences developmental delay. Maternal mental health represents one of the earliest, modifiable influences in a child's life. The objective of the review was to evaluate the association between maternal mental health and school-age child development, and we hypothesized there would be a negative association. Five databases were searched (Embase, CINAHL, Eric, PsycInfo, Medline). Key journals and reference lists were hand-searched. Two reviewers assessed studies based on inclusion criteria: (1) the exposure was any form of maternal mental health occurring during pregnancy or postpartum periods; (2) the outcome was child development (>48 months to 8 years); (3) the study recruited participants from developed countries; and (4) publication was in English between January, 1990 and December, 2012. Disagreements were resolved by consensus. Study quality was assessed by two reviewers using the Scottish Intercollegiate Guideline Network and disagreements were resolved by consensus. Data extraction was conducted by one reviewer using standardized forms. Maternal mental health problems in pregnancy and/or the postpartum period increased the likelihood that school-age children experienced suboptimal global, behavioral, cognitive, and socio-emotional development. The findings highlight the need for maternal mental health assessment during the prenatal, postnatal, and early childhood periods.

Risk factors for preterm birth and small-for-gestational-age births among Canadian women.

BACKGROUND: Preterm births (PTB) and small-for-gestational-age (SGA) births are distinct but related pregnancy outcomes, with differing aetiologies and short and long-term morbidities. Few studies have compared a broad array of predictors among these two outcomes. The purpose of this study was to compare risk factors for PTB and SGA births using a national sample of Canadian women. METHODS: We analysed data from the Canadian Maternity Experiences Survey (n = 6421). Mothers were ≥ 15 years of age, gave birth to a singleton infant and were living with their infant at the time of the interview (between 5 and 14 months post-partum). Backward stepwise multivariable logistic regression models were constructed for each outcome. RESULTS: Risk profiles for the two outcomes had both differences and similarities. Risk factors specific to PTB were education less than high school, having a previous medical condition, developing a new medical condition or health problem during pregnancy, being a primigravida, or being a multigravida with a previous PTB or a previous miscarriage or abortion. Risk factors unique to SGA were low pre-pregnancy body mass index (<18 kg/m(2) ), smoking during pregnancy and being a recent immigrant. Risk factors for both outcomes included low weight gain during pregnancy (<9.1 kg), short stature (<155 cm) and reporting life as 'very stressful' in the year prior to birth of the baby. CONCLUSION: A greater understanding of the risk factors related to PTB and SGA may help to reduce the prevalence of these conditions and the associated risk of infant mortality and morbidity.

Trajectories of maternal depressive symptoms from pregnancy to 11 years postpartum: Findings from Avon Longitudinal Study of Parents and Children (ALSPAC) cohort.

BACKGROUND: Maternal depressive symptoms are common in pregnancy and may extend to the perinatal period and beyond for some women. To date, few longitudinal studies have investigated maternal depressive symptoms from pregnancy to eleven years postpartum. Drawing data from a large population-based study cohort the aims of this study were to 1) identify distinct groups of mothers defined by their trajectories of depressive symptoms spanning from pregnancy to eleven years following the birth of the child, and 2) to identify psychosocial risk factors during pregnancy and in the first few postnatal years that are associated with these trajectories. METHODS: Data were analyzed from 14,170 mothers who participated in Avon Longitudinal Study of Parents and Children (ALSPAC). The Edinburgh Postnatal Depression Scale (EPDS) was used to capture maternal depressive symptoms across 10 time points including two prenatal (18 and 32 weeks), and eight postnatal (2, 8, 21, 33, 61, 73, 97 and 134 months) time points. The latent growth model was created to describe the course of maternal depressive symptoms across the preceding time points followed by a latent growth mixture modelling (LGMM) to identify distinct trajectories of depressive symptoms over time within the overall sample. The predictors of maternal depressive symptoms trajectories were categorized into sociodemographic, child, and psychosocial factors. The multinomial regression analyses were conducted to explore associations between the risk factors and depressive symptoms trajectories. RESULTS: LGMM identified four distinct trajectories of maternal depressive symptoms over time: minimal symptoms, increasing symptoms, persistent symptoms, and decreasing symptoms. Predictors of all patterns of depression - persistent, increasing and decreasing symptoms include smoking during pregnancy, and partner conflict. The strongest predictors of the persistent symptom trajectory included maternal history of depression and inadequate social support. LIMITATIONS: The use of self-reported maternal mental health symptoms and under representation of ethnic minorities are our study's limitations. CONCLUSIONS: The study findings highlight the importance of early identification and treatment for mothers experiencing depressive symptoms from pregnancy to the perinatal period and beyond.

Development of a prenatal psychosocial screening tool for post-partum depression and anxiety.

BACKGROUND: Post-partum depression (PPD) is the most common complication of pregnancy in developed countries, affecting 10-15% of new mothers. There has been a shift in thinking less in terms of PPD per se to a broader consideration of poor mental health, including anxiety after giving birth. Some risk factors for poor mental health in the post-partum period can be identified prenatally; however prenatal screening tools developed to date have had poor sensitivity and specificity. The objective of this study was to develop a screening tool that identifies women at risk of distress, operationalized by elevated symptoms of depression and anxiety in the post-partum period using information collected in the prenatal period. METHODS: Using data from the All Our Babies Study, a prospective cohort study of pregnant women living in Calgary, Alberta (N = 1578), we developed an integer score-based prediction rule for the prevalence of PPD, as defined as scoring 10 or higher on the Edinburgh Postnatal Depression Scale (EPDS) at 4-months postpartum. RESULTS: The best fit model included known risk factors for PPD: depression and stress in late pregnancy, history of abuse, and poor relationship quality with partner. Comparison of the screening tool with the EPDS in late pregnancy showed that our tool had significantly better performance for sensitivity. Further validation of our tool was seen in its utility for identifying elevated symptoms of postpartum anxiety. CONCLUSION: This research heeds the call for further development and validation work using psychosocial factors identified prenatally for identifying poor mental health in the post-partum period.

Women's and care providers' perspectives of quality prenatal care: a qualitative descriptive study.

BACKGROUND: Much attention has been given to the adequacy of prenatal care use in promoting healthy outcomes for women and their infants. Adequacy of use takes into account the timing of initiation of prenatal care and the number of visits. However, there is emerging evidence that the quality of prenatal care may be more important than adequacy of use. The purpose of our study was to explore women's and care providers' perspectives of quality prenatal care to inform the development of items for a new instrument, the Quality of Prenatal Care Questionnaire. We report on the derivation of themes resulting from this first step of questionnaire development. METHODS: A qualitative descriptive approach was used. Semi-structured interviews were conducted with 40 pregnant women and 40 prenatal care providers recruited from five urban centres across Canada. Data were analyzed using inductive open and then pattern coding. The final step of analysis used a deductive approach to assign the emergent themes to broader categories reflective of the study's conceptual framework. RESULTS: The three main categories informed by Donabedian's model of quality health care were structure of care, clinical care processes, and interpersonal care processes. Structure of care themes included access, physical setting, and staff and care provider characteristics. Themes under clinical care processes were health promotion and illness prevention, screening and assessment, information sharing, continuity of care, non-medicalization of pregnancy, and women-centredness. Interpersonal care processes themes were respectful attitude, emotional support, approachable interaction style, and taking time. A recurrent theme woven throughout the data reflected the importance of a meaningful relationship between a woman and her prenatal care provider that was characterized by trust. CONCLUSIONS: While certain aspects of structure of care were identified as being key dimensions of quality prenatal care, clinical and interpersonal care processes emerged as being most essential to quality care. These processes are important as they have a role in mitigating adverse outcomes, promoting involvement of women in their own care, and keeping women engaged in care. The findings suggest key considerations for the planning, delivery, and evaluation of prenatal care. Most notably, care should be woman-centred and embrace shared decision making as an essential element.

Factors associated with perceived stress and stressful life events in pregnant women: findings from the Canadian Maternity Experiences Survey.

Prenatal maternal stress has been linked to multiple adverse outcomes. Researchers have used a variety of methods to assess maternal stress. The purpose of this study was to explore and compare factors associated with stress in pregnancy as measured by perceived stress and stressful life events. We analyzed data from the Canadian Maternity Experiences Survey. A randomly selected sample of 8,542 women who had recently given birth was drawn from the 2006 Canadian Census. Women were eligible if they were at least 15 years of age, had delivered a live, singleton infant, and were living with their infant at the time of the interview (5-14 months postpartum). Prevalence estimates and odds ratios were calculated using sample weights of the survey and their variances were calculated using bootstrapping methods. Bivariate analyses identified statistically significant factors associated with each stress measure. Backward stepwise multivariate logistic regression models were constructed. A total of 6,421 women (78%) participated in the computer assisted telephone interview. Twelve percent of women experienced high levels of perceived stress and 17.1% reported having three or more stressful life events in the year prior to the birth of their baby. In the final model, psychosocial variables were associated with both outcomes, whereas demographic factors were associated only with life event stress. Different factors contributed to perceived stress and life event stress, suggesting that these concepts measure different aspects of stress. These findings can inform routine psychosocial risk assessment in pregnancy.

Prenatal and postpartum maternal psychological distress and infant development: a systematic review.

Infant development plays a foundational role in optimal child development and health. Some studies have demonstrated an association between maternal psychological distress and infant outcomes, although the main emphasis has been on postpartum depression and infant-maternal attachment. Prevention and early intervention strategies would benefit from an understanding of the influence of both prenatal and postpartum maternal distress on a broader spectrum of infant developmental outcomes. We conducted a systematic review of studies assessing the effect of prenatal and postpartum maternal psychological distress on five aspects of infant development: global; cognitive; behavioral; socio-emotional; and psychomotor. These findings suggest that prenatal distress can have an adverse effect on cognitive, behavioral, and psychomotor development, and that postpartum distress contributes to cognitive and socio-emotional development.

The complexity of postpartum mental health and illness: a critical realist study.

The complexity of postpartum mental health and illness: a critical realist study Postpartum depression (PPD) is a major public health issue that profoundly impacts the woman, her infant and family. Although it may be linked to hormone changes, no direct hormonal aetiology has been established. A large body of evidence implicates numerous psychosocial predictors of PPD. While a history of depression predicts about 50% of cases of PPD, it remains unclear why some women with a history do not develop depression following childbirth, even taking psychosocial factors into account. The aim of this study was to identify the main mechanisms and factors associated with the presence or absence of PPD in women with a history of depression, and the presence of PPD in women without a history, using a critical realist approach. The findings indicate a number of personal and contextual factors that influence postpartum mental health and illness. In addition, and perhaps most importantly, women who did not develop depression identified goal-oriented actions that were protective. These factors and processes did not exist in isolation and the interplay among them in influencing health was apparent. More research is needed to explore the effects of these mechanisms in different contexts.

The clinical performance and cost-effectiveness of two psychosocial assessment models in maternity care: The Perinatal Integrated Psychosocial Assessment study.

PROBLEM: Although perinatal universal depression and psychosocial assessment is recommended in Australia, its clinical performance and cost-effectiveness remain uncertain. AIM: To compare the performance and cost-effectiveness of two models of psychosocial assessment: Usual-Care and Perinatal Integrated Psychosocial Assessment (PIPA). METHODS: Women attending their first antenatal visit were prospectively recruited to this cohort study. Endorsement of significant depressive symptoms or psychosocial risk generated an 'at-risk' flag identifying those needing referral to the Triage Committee. Based on its detailed algorithm, a higher threshold of risk was required to trigger the 'at-risk' flag for PIPA than for Usual-Care. Each model's performance was evaluated using the midwife's agreement with the 'at-risk' flag as the reference standard. Cost-effectiveness was limited to the identification of True Positive and False Positive cases. Staffing costs associated with administering each screening model were quantified using a bottom-up time-in-motion approach. FINDINGS: Both models performed well at identifying 'at-risk' women (sensitivity: Usual-Care 0.82 versus PIPA 0.78). However, the PIPA model was more effective at eliminating False Positives and correctly identifying 'at-risk' women (Positive Predictive Value: PIPA 0.69 versus Usual Care 0.41). PIPA was associated with small incremental savings for both True Positives detected and False Positives averted. DISCUSSION: Overall PIPA performed better than Usual-Care as a psychosocial screening model and was a cost-saving and relatively effective approach for detecting True Positives and averting False Positives. These initial findings warrant evaluation of longer-term costs and outcomes of women identified by the models as 'at-risk' and 'not at-risk' of perinatal psychosocial morbidity.