Teaching by texting to promote positive health behaviours in pregnancy: a protocol for a randomised controlled trial of SmartMom.

INTRODUCTION: Prenatal education is associated with positive health behaviours, including optimal weight gain, attendance at prenatal care, acceptance of routine screening tests, smoking cessation, decreased alcohol consumption and breast feeding. Adoption of these behaviours has been associated with reduced rates of caesarean birth, preterm birth and low birth weight. Barriers to prenatal class attendance faced by parents in Canada include geography, socioeconomic status, age, education, and, among Indigenous peoples and other equity-deserving groups, stigma. To address the need for easily accessible and reliable information, we created 'SmartMom', Canada's first prenatal education programme delivered by short message service text messaging. SmartMom provides evidence-based information timed to be relevant to each week of pregnancy. The overall goal of SmartMom is to motivate the adoption of positive prenatal health behaviours with the ultimate goal of improving health outcomes among women and their newborns. METHODS AND ANALYSIS: We will conduct a two-arm single-blinded randomised controlled trial. Blinding of participants to trial intervention will not be possible as they will be aware of receiving the intervention, but data analysts will be blinded. Our primary research questions are to determine if women experiencing uncomplicated pregnancies randomly assigned to receive SmartMom messages versus messages addressing general topics related to pregnancy but without direction for behaviour change, have higher rates of: (1) weight gain within ranges recommended for prepregnancy body mass index and (2) adherence to Canadian guidelines regarding attendance at prenatal care appointments. ETHICS AND DISSEMINATION: The study has been granted a Certificate of Approval, number H22-00603, by the University of British Columbia Research Ethics Board. To disseminate our findings, we are undertaking both integrated and end-of-grant knowledge translation, which will proactively involve potential end-users and stakeholders at every phase of our project. TRIAL REGISTRATION NUMBER: NCT05793944.

Feasibility and acceptability of collecting umbilical cord tissue for prenatal cannabis research: A mixed-methods research study.

BACKGROUND: Large-scale longitudinal studies with biological samples are needed to examine the associations between prenatal cannabis use and birth and developmental outcomes. OBJECTIVES: The aim of this study was to understand the feasibility and acceptability of collecting umbilical cord tissue for the purpose of cannabis use testing in a community sample. DESIGN: This is a mixed methods research study consisted of a prospective cohort study and a qualitative descriptive study. METHODS: This study was conducted in Vancouver, British Columbia between January 2021 and August 2022. Participants were recruited during pregnancy, and the umbilical cord tissues were collected at birth and tested for the presence of cannabinoids. After the completion of the study, participants completed an online open-ended questionnaire about their overall experience. Data were analyzed using descriptive and thematic analyses. RESULTS: Among the 85 eligible individuals, 57 people (67%) consented to the study. The cord tissue was collected for 39 participants (68.4%). The collection rates for participants with vaginal, elective, and emergency cesarean delivery were 73.0%, 71.4%, and 53.8%, respectively, and for those with spontaneous and induced labor were 81.5% and 50%, respectively. Four (7.0%) and seven participants (12.3%) reported prenatal cannabis use in direct and probing self-report questions, respectively. The agreement between any self-report and cord tissue test was moderate (kappa 0.53, 95% confidence interval 0.06-0.99). Qualitative findings were classified into five themes. CONCLUSION: The collection of cord tissue was perceived acceptable by most participants. Implementation of collection protocols for complex labors, a central hospital unit to liaise direct communications and active participants' involvement might increase the feasibility of future studies.

How do perceptions of Covid-19 risk impact pregnancy-related health decisions? A convergent parallel mixed-methods study protocol.

INTRODUCTION: Pregnant people have a higher risk of severe COVID-19 disease. They have been disproportionately impacted by COVID-19 infection control policies, which exacerbated conditions resulting in intimate partner violence, healthcare access, and mental health distress. This project examines the impact of accumulated individual health decisions and describes how perinatal care and health outcomes changed during the COVID-19 pandemic. OBJECTIVES: Quantitative strand: Describe differences between 2019, 2021, and 2022 birth groups related to maternal vaccination, perinatal care, and mental health care. Examine the differential impacts on racialized and low-income pregnant people.Qualitative strand: Understand how pregnant people's perceptions of COVID-19 risk influenced their decision-making about vaccination, perinatal care, social support, and mental health. METHODS AND ANALYSIS: This is a Canadian convergent parallel mixed-methods study. The quantitative strand uses a retrospective cohort design to assess birth group differences in rates of Tdap and COVID-19 vaccination, gestational diabetes screening, length of post-partum hospital stay, and onset of depression, anxiety, and adjustment disorder, using administrative data from ICES, formerly the Institute for Clinical Evaluative Sciences (Ontario) and PopulationData BC (PopData) (British Columbia). Differences by socioeconomic and ethnocultural status will also be examined. The qualitative strand employs qualitative description to interview people who gave birth between May 2020- December 2021 about their COVID-19 risk perception and health decision-making process. Data integration will occur during design and interpretation. ETHICS AND DISSEMINATION: This study received ethical approval from McMaster University and the University of British Columbia. Findings will be disseminated via manuscripts, presentations, and patient-facing infographics. TRIAL REGISTRATION: Registration: Clinicaltrials.gov registration number: NCT05663762.

Pregnancy-Specific Anxiety Tool (PSAT): Instrument Development and Psychometric Evaluation.

Objective: Pregnancy-specific anxiety (PSA) is a distinct construct from general anxiety and depression. The purpose of this study was to develop, evaluate, and validate the Pregnancy-Specific Anxiety Tool (PSAT), to measure PSA and its severity.Methods: The study was carried out in 2 stages. Stage 1 involved item development and content and face validation. Stage 2 included psychometric evaluation to examine item distributions and correlational structure, dimensionality, internal consistency reliability, stability, and construct, convergent, and criterion validity, using 2 independent samples (initial sample N = 494, May-October 2018; validation sample N = 325, July 2019-May 2020).Results: Eighty-two items were evaluated for face validity and 41 items were considered in stage 2 based on feedback from participants and experts. Model fit from exploratory factor analysis and patterns of item-factor loadings suggested a 6-factor model with 33 items. The 6 factors included items pertaining to health and well-being of the baby, labor and the pregnant person's well-being, postpartum, support, career and finance, and indicators of severity. Confirmatory factor analysis carried out using the initial sample showed good fit with the validation sample. The area under the curve (AUC) for the diagnosis of adjustment disorders (AD) was 0.73 (95% CI, 0.67-0.79), and for AD/any anxiety disorders, the AUC was 0.80 (95% CI, 0.75-0.85).Conclusions: The PSAT can be useful for screening and monitoring of PSA, and pregnant people with scores higher than 10 should be considered for further assessment.

Postpartum people's experiences of and responses to the COVID-19 pandemic during the first year of the pandemic: A descriptive qualitative study.

BACKGROUND: Most evidence on the impact of pandemic on perinatal population's experiences has reported such effects in a portion of the pandemic. OBJECTIVES: The aim of this study was to understand the postpartum people's experiences of and responses to the coronavirus disease 2019 pandemic during the first year and to identify their health care needs. DESIGN: This is a descriptive qualitative study. METHODS: This study was conducted in British Columbia, Canada, between March 2020 and April 2021. Participants (N = 268) were at 4 months postpartum and were recruited as part of the Pregnancy Specific Anxiety Tool study through prenatal care clinics and classes, community laboratory services and social media. Qualitative data were obtained using six online open-ended questions and were analysed using thematic analysis. RESULTS: Findings were grouped under five central themes: protecting baby (with three categories including hypervigilance, constant decision-making to find balance and developmental issues); psychological adjustments (with three categories including coping, anxiety and grief); experience of isolation and lack/loss of support (with two categories including isolation and loss of expected support); unexpected interruptions and life events (with four categories including interrupted maternity leave, unexpected changes/life events, positive impacts and interruption in health care services); and perceived postpartum care needs (with five categories including in-person visits, allowing support persons, providing information/education/support groups, mental health and social support and pro-active check-ins). CONCLUSION: Several impacts of the pandemic persisted throughout the first year, particularly isolation and lack of support. These findings can inform responsive health care services to address the emerging needs of postpartum people throughout the pandemic.

Experience of pregnancy during family medicine residency: Qualitative research study.

OBJECTIVE: To explore the challenges that childbearing family medicine residents encounter during postgraduate training and to understand the available support systems. DESIGN: Descriptive qualitative research study. SETTING: British Columbia, Canada. PARTICIPANTS: Nine University of British Columbia family medicine residents who experienced pregnancy during their residencies between 2014 and 2018. METHODS: Semistructured telephone interviews with family medicine residents were conducted until data reached saturation. Audiorecorded interviews were transcribed and analyzed using content analysis with an iterative approach to elucidate themes. Member checking and peer debriefing were used to ensure the rigour of the findings. MAIN FINDINGS: The participants reported various unique challenges during pregnancy, maternity leave, and return to work. Residents during pregnancy tended to prioritize work over one's own well-being and reported an increased level of perceived adverse symptoms. During maternity leave, residents reported postpartum depression, anxiety, and conflict between the roles of parent and physician. Upon return to work, participants perceived a decrease in their clinical function and reported feelings of guilt and anxiety because of the shared burden of residency with family. Residents found their programs supportive throughout pregnancy and maternity leave; however, a decrease in support upon return to work was a recurring theme in responses. CONCLUSION: Pregnancy during family medicine residency has unique challenges, necessitating support from programs, preceptors, and colleagues. Further resources and incentives are needed to facilitate the transition back to work after maternity leave.

Measurement of pregnancy-related anxiety worldwide: a systematic review.

BACKGROUND: The perinatal period is often characterized by specific fear, worry, and anxiety concerning the pregnancy and its outcomes, referred to as pregnancy-related anxiety. Pregnancy-related anxiety is uniquely associated with negative maternal and child health outcomes during pregnancy, at birth, and early childhood; as such, it is increasingly studied. We examined how pregnancy-related anxiety is measured, where measures were developed and validated, and where pregnancy-related anxiety has been assessed. We will use these factors to identify potential issues in measurement of pregnancy-related anxiety and the geographic gaps in this area of research. METHODS: We searched the Africa-Wide, CINAHL, MEDLINE, PsycARTICLES, PsycINFO; PubMed, Scopus, Web of Science Core Collection, SciELO Citation Index, and ERIC databases for studies published at any point up to 01 August 2020 that assessed pregnancy-related anxiety. Search terms included pregnancy-related anxiety, pregnancy-related worry, prenatal anxiety, anxiety during pregnancy, and pregnancy-specific anxiety, among others. Inclusion criteria included: empirical research, published in English, and the inclusion of any assessment of pregnancy-related anxiety in a sample of pregnant women. This review is registered on PROSPERO (CRD42020189938). RESULTS: The search identified 2904 records; after screening, we retained 352 full-text articles for consideration, ultimately including 269 studies in the review based on the inclusion and exclusion criteria. In total, 39 measures of pregnancy-related anxiety were used in these 269 papers, with 18 used in two or more studies. Less than 20% of the included studies (n = 44) reported research conducted in low- and middle-income country contexts. With one exception, all measures of pregnancy-related anxiety used in more than one study were developed in high-income country contexts. Only 13.8% validated the measures for use with a low- or middle-income country population. CONCLUSIONS: Together, these results suggest that pregnancy-related anxiety is being assessed frequently among pregnant people and in many countries, but often using tools that were developed in a context dissimilar to the participants' context and which have not been validated for the target population. Culturally relevant measures of pregnancy-related anxiety which are developed and validated in low-income countries are urgently needed.

Pregnant people's responses to the COVID-19 pandemic: a mixed-methods, descriptive study.

BACKGROUND: Given the extent of the COVID-19 pandemic and uncertainty around the timing of its containment, understanding the experiences and responses of the perinatal population is essential for planning responsive maternity care both during and after the pandemic. The aim of this study was to explore the experiences of pregnant people and their responses to the COVID-19 pandemic, and to identify how health care providers can support this population. METHODS: This was a mixed-methods, descriptive study with cross-sectional and qualitative descriptive components. We conducted the study between Mar. 20 and May 31, 2020, in British Columbia, Canada. Any pregnant person at any gestational age living in BC was eligible to participate. We collected quantitative data using online survey tools, including the Edinburgh Postnatal Depression Scale (EPDS) and the 7-item Generalized Anxiety Disorder questionnaire (GAD-7). We collected qualitative data using open-ended questions to explore people's thoughts, feelings and experiences during the pandemic. Participants were recruited using study posters distributed via prenatal care clinics and classes, LifeLabs and social media across the province. We used thematic and descriptive analyses to analyze the data, and we integrated the qualitative and quantitative findings at the interpretation level. RESULTS: The study sample included 96 participants with mean (± standard deviation) maternal and gestational ages of 32 ± 3.92 years and 22.73 ± 8.93 weeks, respectively. Most (93%; n = 89) identified as female. Of the participants, 54% (n = 50) and 35% (n = 34) reported anxiety and depressive symptoms, as measured by the GAD-7 and EPDS, respectively. Overarching themes that emerged from the qualitative data included uncertainty about birth plans and setting, added burden to existing health and social disparities, perceived or projected lack of support or limited support, concerns about early development, and struggle over managing multiple demands. Perceived maternity care needs included mental health support, maintaining prenatal care, frequent and proactive check-ins to build rapport, and recommendations specific to the pandemic. INTERPRETATION: We found that the impact of the COVID-19 pandemic on the pregnant population has been substantial. The findings of this mixed-methods study can be used to help plan informed and evidence-based health care interventions to mitigate adverse effects and support mothers and families.

Cannabis Use During the Pre-Conception Period and Pregnancy After Legalization.

OBJECTIVE: There is limited evidence of the impact of cannabis legalization on the prevalence of cannabis use and use of other substances. The aim of this exploratory observational study was to compare rates of cannabis use, cigarette smoking, alcohol consumption, and the use of any street drugs during the preconception period and in pregnancy in two convenience samples of pregnant persons in British Columbia, Canada, before and after the legalization of cannabis. METHODS: Any pregnant person residing in British Columbia, aged >19 years, at any gestational age was eligible to participate. Pre- and post-legalization study participants were recruited between May and October 2018 and July 2019 and May 2020, respectively. Multivariate models were constructed to examine the effect of legalization on cigarette smoking and the use of cannabis, alcohol, and street drugs, adjusting for demographic, pre-pregnancy, and pregnancy confounders. RESULTS: From pre- to post-legalization, the prevalence of self-reported cannabis use during the preconception period increased significantly, from 11.74% (95% CI 9.19%-14.88%) to 19.38% (95% CI 15.45%-24.03%). Rates of cannabis use during pregnancy also increased from 3.64% (95% CI 2.32%-5.69%) before legalization to 4.62% (95% CI 2.82%-7.47%) after; however, this difference was not statistically significant. Adjusting for potential confounders, the post-legalization group had significantly higher odds of cannabis use during the preconception period (adjusted odds ratio 1.71; 95% CI 1.14-2.58) but not during pregnancy (adjusted odds ratio 1.66; 95% CI 0.75-3.65). Legalization was also not associated with significant changes in cigarette smoking, alcohol consumption, or the use of street drugs during the preconception period and pregnancy, after adjusting for potential confounders. CONCLUSION: The preliminary evidence presented in this study shows that the legalization of cannabis was associated with 71% higher odds of cannabis use during the preconception period. Studies examining the effects of cannabis use on perinatal outcomes, as well as public health interventions and educational programs related to cannabis use, should include the preconception period as an area of focus.

Perinatal outcomes of planned home birth after cesarean and planned hospital vaginal birth after cesarean at term gestation in British Columbia, Canada: A retrospective population-based cohort study.

BACKGROUND: The aim of this retrospective population-based cohort study was to determine whether the mode of delivery and maternal and neonatal outcomes differ between planned home VBAC (HBAC) and planned hospital VBAC. METHODS: All midwifery clients with at least one prior cesarean birth delivered between April 2000 and March 2017 (N = 4741; n = 4180 planned hospital VBAC, n = 561 planned HBAC) were included. Multivariate binomial logistic regression analyses were conducted to calculate the odds ratios adjusted for the potential covariates. The primary outcome was the mode of delivery, and the secondary outcomes were uterine rupture/dehiscence, postpartum hemorrhage, nonintact perineum, episiotomy, obstetric trauma, Apgar score <7 at 5 minutes, neonatal resuscitation requiring positive pressure ventilation, neonatal intensive care unit admission, and a composite outcome of severe neonatal mortality and morbidity and maternal mortality and morbidity. RESULTS: Planned HBAC was associated with a significant 39% decrease in the odds of having a cesarean birth (aOR 0.61, 95% CI 0.47-0.79) adjusting for the prepregnancy and pregnancy characteristics. Severe adverse outcomes were relatively rare in both settings; thus, our study did not have sufficient power to detect the true differences associated with the place of birth. CONCLUSIONS: Home births for those eligible for VBACs and attended by registered midwives within an integrated health system were associated with higher vaginal birth rates compared with planned hospital VBACs. Severe adverse outcomes were relatively rare in both settings.

The Risk of Relapse of Depression During Pregnancy After Discontinuation of Antidepressants: A Systematic Review and Meta-Analysis.

OBJECTIVE: The aim of this systematic review and meta-analysis was to determine the effect of antidepressant discontinuation on the risk of relapse of depression during pregnancy. DATA SOURCES: MEDLINE, EMBASE, CINAHL, and PsycInfo were searched from the inception of each database through March 2019 using keywords such as antidepressants, pregnancy, preconception, discontinuation, stop, recurrence, reintroduction, and relapse. STUDY SELECTION: Original studies that involved pregnant women who discontinued antidepressants during preconception (ie, 3 months prior to pregnancy) or pregnancy and examined the relapse of depression during pregnancy (ie, the reemergence of depression or reintroduction of medication) and published in English were included. A total of 2,172 records were identified, and the full texts of 37 articles were reviewed. Eight studies met the inclusion criteria, 6 of which fulfilled the quality criteria, with 4 studies providing data for the meta-analysis. DATA EXTRACTION: Data were extracted using a data extraction form developed for the purpose of this study. The Cochrane Collaboration Review Manager software version 5.3 was used to conduct the meta-analysis. RESULTS: Pooled data did not show higher risk of relapse of depression during pregnancy for women who discontinued antidepressants than for those who continued antidepressants (risk ratio [RR] = 1.74; 95% CI, 0.97 to 3.10; P = .06). In the subanalysis based on the severity and recurrence of depression in the study populations, the risk of relapse was significantly higher for populations suggestive of severe or recurrent depression (RR = 2.30; 95% CI, 1.58 to 3.35) but not for populations suggestive of mild or moderate depression severity (RR = 1.59; 95% CI, 0.83 to 3.04). CONCLUSIONS: Women with severe or recurrent depression should be informed about the increased risk of relapse following antidepressant discontinuation, and those who discontinue antidepressants should be monitored for relapse.

Association between gestational weight gain and severe adverse birth outcomes in Washington State, US: A population-based retrospective cohort study, 2004-2013.

BACKGROUND: Suboptimal weight gain during pregnancy is a potentially modifiable risk factor. We aimed to investigate the association between suboptimal gestational weight gain and severe adverse birth outcomes by pre-pregnancy body mass index (BMI) categories, including obesity class I to III. METHODS AND FINDINGS: We conducted a population-based study of pregnant women with singleton hospital births in Washington State, US, between 2004 and 2013. Optimal, low, and excess weight gain in each BMI category was calculated based on weight gain by gestational age as recommended by the American College of Obstetricians and Gynecologists and the Institute of Medicine. Primary composite outcomes were (1) maternal death and/or severe maternal morbidity (SMM) and (2) perinatal death and/or severe neonatal morbidity. Logistic regression was used to obtain adjusted odds ratios (AORs) and 95% confidence intervals. Overall, 722,839 women with information on pre-pregnancy BMI were included. Of these, 3.1% of women were underweight, 48.1% had normal pre-pregnancy BMI, 25.8% were overweight, and 23.0% were obese. Only 31.5% of women achieved optimal gestational weight gain. Women who had low weight gain were more likely to be African American and have Medicaid health insurance, while women with excess weight gain were more likely to be non-Hispanic white and younger than women with optimal weight gain in each pre-pregnancy BMI category. Compared with women who had optimal weight gain, those with low gestational weight gain had a higher rate of maternal death, 7.97 versus 2.63 per 100,000 (p = 0.027). In addition, low weight gain was associated with the composite adverse maternal outcome (death/SMM) in women with normal pre-pregnancy BMI and in overweight women (AOR 1.12, 95% CI 1.04-1.21, p = 0.004, and AOR 1.17, 95% CI 1.04-1.32, p = 0.009, respectively) compared to women in the same pre-pregnancy BMI category who had optimal weight gain. Similarly, excess gestational weight gain was associated with increased rates of death/SMM among women with normal pre-pregnancy BMI (AOR 1.20, 95% CI 1.12-1.28, p < 0.001) and obese women (AOR 1.12, 95% CI 1.01-1.23, p = 0.019). Low gestational weight gain was associated with perinatal death and severe neonatal morbidity regardless of pre-pregnancy BMI, including obesity classes I, II, and III, while excess weight gain was associated with severe neonatal morbidity only in women who were underweight or had normal BMI prior to pregnancy. Study limitations include the ascertainment of pre-pregnancy BMI using self-report, and lack of data availability for the most recent years. CONCLUSIONS: In this study, we found that most women do not achieve optimal weight gain during pregnancy. Low weight gain was associated with increased risk of severe adverse birth outcomes, and in particular with maternal death and perinatal death. Excess gestational weight gain was associated with severe adverse birth outcomes, except for women who were overweight prior to pregnancy. Weight gain recommendations for this group may need to be reassessed. It is important to counsel women during pregnancy about specific risks associated with both low and excess weight gain.

Effectiveness of eHealth Interventions to Reduce Perinatal Anxiety: A Systematic Review and Meta-Analysis.

Objective: eHealth interventions have been shown to be effective in improving anxiety among the general population. Despite the effectiveness of eHealth interventions for perinatal depression, a recent review reported mixed results for perinatal anxiety. The review, however, was not focused on anxiety, and studies with various designs were included. The aim of this systematic review is to summarize the evidence specific to anxiety and to conduct a meta-analysis to examine the effectiveness of eHealth interventions in reducing perinatal anxiety. Data Sources: MEDLINE, CINAHL, EMBASE, and PsycINFO were searched beginning with the date that the databases were available through March 2018 using keywords such as perinatal period, web-based interventions, and anxiety. Study Selection: Randomized controlled trials that were conducted during the perinatal period, examined the effectiveness of an eHealth mental health intervention, measured anxiety symptoms or disorders as a primary or secondary outcome, provided data on anxiety levels both pre-intervention and post-intervention, had a comparison group, and were published in English were included. A total of 770 articles were retrieved, and the full texts of 64 articles were reviewed. Five studies met the inclusion criteria, 4 of which fulfilled the quality criteria and were included in the meta-analysis. Data Extraction: Data were extracted using a data extraction form developed for this study. The Cochrane Collaboration's Review Manager software was used to conduct the meta-analysis. Results: The test for heterogeneity (I² = 0%; P = .80) suggested a homogeneous sample. The meta-analysis for the total effect size showed that at post-intervention, the eHealth group had significantly lower anxiety scores than the control group, with a standardized mean difference of -0.41 (95% CI, -0.71 to -0.11; P = .007). Conclusions: eHealth interventions are promising in improving perinatal anxiety. The content of these interventions should account for common comorbid mental health conditions during the perinatal period and provide opportunities to tailor further treatment if necessary.

Women's perspectives about cannabis use during pregnancy and the postpartum period: An integrative review.

Cannabis is the most commonly used illicit drug among general and pregnant populations. Despite recommendations to abstain from cannabis use, its use is increasing during the perinatal period. In this integrative review, we aim to understand women's perspectives about the health aspects of perinatal cannabis use. The following databases were searched: MEDLINE, PsycInfo, EMBASE, and CINAHL. We included quantitative and qualitative studies with a primary focus on perinatal cannabis use. The methodological quality of the included studies was appraised using appropriate checklists. Extracted data were integrated into a single data matrix and iteratively compared across studies to summarize and synthesize the data. Full text of 33 citations was retrieved and reviewed of which 6 studies met the inclusion criteria. Women who continued to use cannabis during pregnancy often perceived no general or pregnancy-specific risk compared to nonusers. The uncertainty regarding adverse perinatal consequences, its perceived therapeutic effects, and lower costs of cannabis compared to that of cigarettes contributed to cannabis use. A lack of communication with health care providers regarding the health aspects of cannabis was evident. Women perceived this lack of counseling as an indication that adverse outcomes associated with cannabis use are not significant. Women's perceptions of health risks associated with cannabis use are important factors in the decision-making process regarding use or cessation, particularly as legal concerns are fading away. A discussion about health concerns surrounding cannabis use may influence women's perceptions of risk and help them to make informed choices.

Risk factors for antenatal anxiety: A systematic review of the literature.

BACKGROUND: Given the prevalence of antenatal anxiety and its consistent associations with adverse pregnancy and child outcomes, early detection and management of anxiety are essential. OBJECTIVE: The aim was to identify risk factors for anxiety among pregnant women by systematically reviewing original research. METHODS: Cross-sectional, case-control and cohort studies that examined associations between antenatal anxiety and at least one potential risk factor prospectively or retrospectively and measured anxiety independent from other mental health conditions were included. Studies rated strong/moderate in methodological quality appraisal were used to synthesise the evidence. RESULTS: Factors associated with greater risk of anxiety included previous pregnancy loss, medical complications, childhood abuse, intimate partner violence, denial/acceptance coping styles, personality traits, inadequate social support, history of mental health problems, high perceived stress and adverse life events. CONCLUSIONS: Several risk factors identified in this review are detectable in routine prenatal care visits (e.g. previous pregnancy loss, pregnancy complications), potentially modifiable (e.g. coping styles, social support, partner factors) and can be identified prior to pregnancy (e.g. psychosocial factors), underlining the significance of pre-conception mental health screening.

Vulnerable Women's Perceptions of Individual Versus Group Prenatal Care: Results of a Cross-Sectional Survey.

Introduction Vulnerable pregnant women (e.g. women with low socio-economic status or recent immigrants) are less likely to receive adequate prenatal care or to attend perinatal education classes. CenteringPregnancy (CP) is a model of group prenatal care which combines assessment, education and support. This study aimed to assess patient experience among vulnerable women in group prenatal care compared to individual care. Methods Women participating in CP at a community-based health centre in urban Alberta were eligible to participate. A convenience sample of women who received individual care at a low-risk maternity clinic served as comparison. Women were asked a series of questions on their prenatal care experience. Demographic and patient responses were compared using Chi square, fisher's exact and t tests. Results Forty-five women accessing CP and 92 women accessing individual care participated. Women in CP were younger, more likely to be single and having their first baby than women in individual care. Women in CP were significantly more likely to report having received enough information on exercise during pregnancy (92 vs. 66%, p = 0.002), breastfeeding (95 vs. 70%, p = 0.002) and baby care (95 vs. 67%, p = 0.001). Women in CP were more likely to report that they felt their prenatal care providers were interested in how the pregnancy was affecting their life (100 vs. 93%, p ≤ 0.001). Discussion Group prenatal care provides a positive experience and improved information exchange among vulnerable populations. Programs interested in engaging, educating and empowering vulnerable pregnant women may benefit from implementation of group care.

Barriers to addressing perinatal mental health issues in midwifery settings.

BACKGROUND: poor perinatal mental health is linked to various adverse pregnancy and child outcomes. Despite having a holistic philosophy of care, similar to other maternity care settings, perinatal mental health issues often remain under-diagnosed and untreated in midwifery settings. AIM: to determine midwives' perceived barriers to the screening, referral, and management of perinatal mental health issues. DESIGN: integrative review. METHODS: the following databases were searched: MEDLINE, CINAHL, EMBASE, and PsycINFO. We included qualitative, quantitative, and mixed methods studies published in a peer-reviewed journal in English. Two reviewers independently extracted data and subsequently integrated the extracted data into a single data matrix. The data matrix was compared iteratively across primary data sources to identify themes and sub-themes. The identified barriers to screening, management and referrals were subsequently categorized into provider-level and system-level barriers. The relevance and methodological quality of the included studies were evaluated using appropriate checklists. FINDINGS: three hundreds and fifty six articles were retrieved. Twenty studies met the inclusion criteria and were included. Insufficient/lack of training, lack of clarity regarding the scope of practice and time constraints were common provider level barriers across various stages of addressing mental health issues from identification to management. The system-level barriers were more complex and diverse and included unclear pathways and unlinked services, lack of local guidelines or policies, continuity of care, structured office procedures, clinical support and supervision and accessible educational resources, scarcity of available referral resources, complex bureaucratic processes and challenges related to expansion of the scope of practice. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: training, expansion of the scope of practice and collaborative care are central for successful screening, management and appropriate and timely referrals of perinatal mental health issues. An integrative model of care may address fragmentation in perinatal mental health services and enable a holistic midwifery care.

A qualitative inquiry on pregnant women's preferences for mental health screening.

BACKGROUND: Approaches to screening can influence the acceptance of and comfort with mental health screening. Qualitative evidence on pregnant women's comfort with different screening approaches and disclosure of mental health concerns is scant. The purpose of this study was to understand women's perspectives of different mental health screening approaches and the perceived barriers to the communication and disclosure of their mental health concerns during pregnancy. METHODS: A qualitative descriptive study was undertaken. Fifteen women, with a singleton pregnancy, were recruited from a community maternity clinic and a mental health clinic in Calgary, Canada. Semi-structured interviews were conducted during both the 2nd and 3rd trimesters. Data were analyzed using thematic analysis. RESULTS: Preferences for mental health screening approaches varied. Most women with a known mental health issue preferred a communicative approach, while women without a known mental health history who struggled with emotional problems were inclined towards less interactive approaches and reported a reluctance to share their concerns. Barriers to communicating mental health concerns included a lack of emotional literacy (i.e., not recognizing the symptoms, not understanding the emotions), fear of disclosure outcomes (i.e., fear of being judged, fear of the consequences), feeling uncomfortable to be seen vulnerable, perception about the role of prenatal care provider (internal barriers); the lack of continuity of care, depersonalized care, lack of feedback, and unfamiliarity with/uncertainty about the availability of support (structural barriers). CONCLUSIONS: The overlaps between some themes identified for the reasons behind a preferred screening approach and barriers reported by women to communicate mental health concerns suggest that having options may help women overcome some of the current disclosure barriers and enable them to engage in the process. Furthermore, the continuity of care, clarity around the outcomes of disclosing mental health concerns, and availability of immediate support can help women move from providing "the best answer" to providing an authentic answer.

The Impact of Introducing Centering Pregnancy in a Community Health Setting: A Qualitative Study of Experiences and Perspectives of Health Center Clinical and Support Staff.

Objectives Introducing new programming into an existing setting may be challenging. Understanding how staff and clinicians who are not directly involved in program delivery view the program can help support program implementation. This study aimed to understand how peripheral staff and clinicians perceived a newly implemented Centering Pregnancy group prenatal care program in a community-based health center and its impact on clinic operations. Methods Semi-structured interviews were conducted with a purposive sample of 12 staff members at a community-based health center. The interview guide covered topics such as perceptions of Centering Pregnancy and how the program impacted their work. An interpretive description approach was used to analyze the interview data. A coding framework was developed iteratively and all interview data were analyzed independently by multiple researchers. Results Staff had overall positive perceptions of Centering Pregnancy, but the level of understanding about the program varied widely. Most respondents viewed the Centering Pregnancy program as separate from other programs offered by the clinic, which created both opportunities and challenges. Opportunities included increased cross-referrals between established services and Centering Pregnancy. Challenges included a lack of communication about responsibilities of staff in relation to Centering Pregnancy patients. Impact on staff and overall clinic operations was perceived to be minimal to moderate, and most tensions related to roles and expectations were resolved. Conclusions for Practice Clear communication regarding fit within clinic structures and processes and expectations of staff in relation to the program was critical to the integration of Centering Pregnancy program into an established health center.

Maternal History of Childhood Abuse and Risk of Asthma and Allergy in 2-Year-Old Children.

OBJECTIVES: Exposure to child abuse (CA) is associated with an increased risk of developing asthma and allergies; it is unknown if that risk is present across generations. This study investigated if 2-year-old children born to mothers with a history of CA were at an increased risk of receiving a diagnosis of asthma or allergies. METHODS: Data from 1,551 participants were collected as part of the All Our Babies (AOB) study, a prospective pregnancy cohort. During pregnancy, each woman provided information about her own history of CA, and at 24 months postpartum, she provided information about her child's medical diagnoses. Symptoms of maternal depression and anxiety were assessed during pregnancy and at 24 months postpartum. RESULTS: Unadjusted models showed that compared to children born to mothers without a history of CA, 2-year-old children born to mothers with a history of CA were more likely to have had a diagnosis of asthma (7.4% vs 4.2%, p = .016) or allergy (15.6% vs 9.2%, p < .001). Maternal symptoms of depression assessed in late pregnancy and symptoms of depression and anxiety at 24 months postpartum were significant mediators of the relationship between maternal CA and 2-year-old asthma diagnosis. Maternal symptoms of depression and anxiety assessed in late pregnancy were also significant mediators of the relationship between maternal CA and 2-year-old allergy diagnosis. CONCLUSIONS: The results indicate that maternal exposure to CA is associated with increased risk of asthma and allergy in their 2-year-old children; symptoms of maternal depression and anxiety were identified as pathways linking the variables.