Impacts of the Attachment and Child Health (ATTACHTM) Parenting Program on Mothers and Their Children at Risk of Maltreatment: Phase 2 Results.

Early adversity (e.g., family violence, parental depression, low income) places children at risk for maltreatment and negatively impacts developmental outcomes. Optimal parental reflective function (RF), defined as the parent's ability to think about and identify thoughts, feelings, and mental states in themselves and in their children, is linked to secure attachment and may protect against suboptimal outcomes. We present the results of Phase 2 randomized control trials (RCTs) and quasi-experimental studies (QES) of the Attachment and Child Health (ATTACHTM) parental RF intervention for families with children at risk for maltreatment. Phase 2 parents experiencing adversity, along with their children aged 0-5 years (n = 45), received the 10-12-week ATTACHTM intervention. Building on completed Phase 1 pilot data, Phase 2 examined outcomes of long-standing interest, including parental RF and child development, as well as new outcomes, including parental perceived social support and executive function, and children's behavior, sleep, and executive function. RCTs and QES revealed significant improvements in parents' RF, perception of social support, and executive function, children's development (i.e., communication, problem-solving, personal-social, and fine motor skills), and a decrease in children's sleep and behavioral problems (i.e., anxiety/depression, attention problems, aggressive behavior, and externalizing problems), post-intervention. ATTACH™ positively impacts parental RF to prevent negative impacts on children at risk of maltreatment.

Association between maternal reflective function and preschool children's cognitive abilities.

Children's cognitive abilities (e.g., working memory) are associated with mental health, adaptive behaviors, and academic achievement, and may be enhanced by parental reflective function (i.e., capacity to reflect on mental states, feelings, thoughts, and intentions in one's child and oneself). We evaluated associations between maternal reflective function and children's cognitive abilities alone and while controlling for parent-child attachment and interaction quality, and psychosocial (i.e., maternal depressive symptoms, adverse childhood experiences) and sociodemographic (e.g., socioeconomic status) factors. Our sample, recruited in Canada, was primarily white and included 73 mothers and their 4-5 year old preschool children. Maternal reflective function was measured with the Reflective Functioning Scale applied to the Parent Development Interview and the Parental Reflective Functioning Questionnaire. Multiple regression analyses revealed that maternal reflective function was associated with children's cognitive abilities. The Parent Development Interview rated child-reflective function was associated with children's higher verbal comprehension alone and while adjusting for covariates (e.g., parent-child interaction quality, socioeconomic status), and the Parental Reflective Functioning Questionnaire Interest and Curiosity with higher verbal comprehension while adjusting for parent-child interactions and attachment pattern. The Parental Reflective Functioning Questionnaire Certainty in Mental States was associated with higher working memory scores for children while adjusting for covariates. Full Scale IQ and Visual Spatial Index were not significantly associated with maternal reflective function. Associations were found between secure and disorganized attachment with higher verbal comprehension and lower working memory, respectively. These findings highlight the importance of high maternal reflective function to cognitive abilities in early childhood.

Study protocol for Attachment & Child Health (ATTACHTM) program: promoting vulnerable Children's health at scale.

BACKGROUND: Children's exposure to toxic stress (e.g., parental depression, violence, poverty) predicts developmental and physical health problems resulting in health care system burden. Supporting parents to develop parenting skills can buffer the effects of toxic stress, leading to healthier outcomes for those children. Parenting interventions that focus on promoting parental reflective function (RF), i.e., parents' capacity for insight into their child's and their own thoughts, feelings, and mental states, may understand help reduce societal health inequities stemming from childhood stress exposures. The Attachment and Child Health (ATTACHTM) program has been implemented and tested in seven rapid-cycling pilot studies (n = 64) and found to significantly improve parents' RF in the domains of attachment, parenting quality, immune function, and children's cognitive and motor development. The purpose of the study is to conduct an effectiveness-implementation hybrid (EIH) Type II study of ATTACHTM to assess its impacts in naturalistic, real-world settings delivered by community agencies rather than researchers under more controlled conditions. METHODS: The study is comprised of a quantitative pre/post-test quasi-experimental evaluation of the ATTACHTM program, and a qualitative examination of implementation feasibility using thematic analysis via Normalization Process Theory (NPT). We will work with 100 families and their children (birth to 36-months-old). Study outcomes include: the Parent Child Interaction Teaching Scale to assess parent-child interaction; the Parental Reflective Function and Reflective Function Questionnaires to assess RF; and the Ages and Stages Questionnaire - 3rd edition to examine child development, all administered pre-, post-, and 3-month-delayed post-assessment. Blood samples will be collected pre- and post- assessment to assess immune biomarkers. Further, we will conduct one-on-one interviews with study participants, health and social service providers, and administrators (total n = 60) from each collaborating agency, using NPT to explore perceptions and experiences of intervention uptake, the fidelity assessment tool and e-learning training as well as the benefits, barriers, and challenges to ATTACHTM implementation. DISCUSSION: The proposed study will assess effectiveness and implementation to help understand the delivery of ATTACHTM in community agencies. TRIAL REGISTRATION: Name of registry: https://clinicaltrials.gov/. REGISTRATION NUMBER: NCT04853888 . Date of registration: April 22, 2021.

Effect of Attachment and Child Health (ATTACHTM) Parenting Program on Parent-Infant Attachment, Parental Reflective Function, and Parental Depression.

High-risk families exposed to toxic stressors such as family violence, depression, addiction, and poverty, have shown greater difficulty in parenting young children. In this study, we examined the effectiveness of ATTACHTM, a 10−12 session manualized one-on-one parental Reflective Function (RF)-based parenting program designed for high-risk families. Outcomes of parent-child attachment and parental RF were assessed via the Strange Situation Procedure (SSP) and Reflective Function Scale (RFS), respectively. The protective role of ATTACHTM on parental depression was also assessed. Data were available from caregivers and their children < 6 years of age who participated in five pilot randomized control trials (RCTs) and quasi-experimental studies (QES; n = 40). Compared with the control group, caregivers who received the ATTACHTM-program demonstrated a greater likelihood of secure attachment with their children (p = 0.004) and higher parental RF [self (p = 0.004), child (p = 0.001), overall (p = 0.002)] in RCTs. A significant improvement in parental RF (p = 0.000) was also observed in the QES within ATTACHTM group analysis. As attachment security increased, receiving the ATTACHTM program may be protective for depressed caregivers. Results demonstrated the promise of ATTACHTM for high-risk parents and their young children.

The ATTACH™ program and immune cell gene expression profiles in mothers and children: A pilot randomized controlled trial.

BACKGROUND: Children exposed to adversity and toxic stress are at increased risk for poor health across the lifespan, possibly through alterations to immune pathways. Parenting interventions could buffer the effect of adversity on child immune activity. The purpose of this study was to test whether mothers and children who were randomly assigned to a parenting intervention (ATTACH™) had healthier post-intervention immune cell gene expression patterns, as indexed by the Conserved Transcriptional Response to Adversity (CTRA), compared with mothers and children in a wait-list control group. METHODS: A sample of 20 mother-child dyads were recruited from a domestic violence shelter in Calgary, AB, Canada. The ATTACH™ program is a 10-week psycho-educational intervention that fosters maternal reflective function, i.e. how to understand and respond to mental states. Dyads were randomly assigned to an intervention or wait-list group. Dried blood spots were collected from both groups post-intervention, subjected to RNA sequencing, and assessed for CTRA gene expression using mixed effect linear model analysis. Covariates were age, child sex, maternal race/ethnicity, and maternal medication use. RESULTS: In unadjusted models, differences by treatment group were detected, F(1,1794) â€‹= â€‹4.26, p â€‹= â€‹.039. Mothers and children who completed the ATTACH™ intervention had lower CTRA scores, indicating healthier immune cell gene expression profiles (Mn â€‹= â€‹-0.36, SE â€‹= â€‹0.17), compared with mothers and children in the wait-list control group (Mn â€‹= â€‹0.11, SE â€‹= â€‹0.15). Results persisted after controlling for covariates. DISCUSSION: ATTACH™ participation predicted healthier immune cell gene expression profiles post-intervention compared with wait-list controls. Parenting interventions could decrease the impact of toxic stress on maternal-child immune health.

Fidelity Assessment Checklist Development for Community Nursing Research in Early Childhood.

Nurses play an important role in promoting positive childhood development via early interventions intended to support parenting. Despite recognizing the need to deliver vital parenting programs, monitoring fidelity has largely been ignored. Fidelity refers to the degree to which healthcare programs follow a well-defined set of criteria specifically designed for a particular program model. With increasing demands for early intervention programs to be delivered by non-specialists, rigorous yet pragmatic strategies for maintaining fidelity are needed. This paper describes the step-by-step development and evaluation of a program fidelity measure, using the Attachment and Child Health (ATTACH™) parenting program as an exemplar. The overall quality index for program delivery varied between "very good" to "excellent," with a mean of 4.3/5. Development of checklists like the ATTACH™ fidelity assessment checklist enables the systematic evaluation of program delivery and identification of therapeutic components that enable targeted efforts at improvement. In future, research should examine links between program fidelity and targeted outcomes to ascertain if increased fidelity scores yield more favorable effects of parenting programs.

Attachment & Child Health (ATTACH) pilot trials: Effect of parental reflective function intervention for families affected by toxic stress.

Toxic stressors (e.g., parental violence, depression, low income) place children at risk for insecure attachment. Parental reflective function-parents' capacity to understand their own and their child's mental states and thus regulate their own feelings and behavior toward their child-may buffer the negative effects of toxic stress on attachment. Our objective was to test the effectiveness of the Attachment and Child Health (ATTACH) intervention, focusing on improving reflective function and children's attachment security, for at-risk mothers and children <36 months of age. Three pilot studies were conducted with women and children from an inner city agency serving vulnerable, low-income families and a family violence shelter. Randomized control trial (n = 20, n = 10 at enrollment) and quasi-experimental (n = 10 at enrollment) methods tested the effect of the ATTACH intervention on the primary outcome of reflective function scores, from transcribed Parent Development Interviews. Our secondary outcome was children's attachment patterns from Ainsworth's Strange Situation Procedure. Despite some attrition, mixed methods analysis of covariance and t tests revealed significant differences in maternal, child, and overall reflective function, with moderate effect sizes. While more children whose mothers received the ATTACH program were securely attached posttreatment, as compared with controls, significant differences were not observed, which may be due to missing observations (n = 5 cases). Understanding the effectiveness of programs like the ATTACH intervention contributes to improved programs and services to promote healthy development of children affected by toxic stress.

Los factores tóxicos de estrés (v.g. violencia de los padres, depresión, bajos recursos económicos) colocan a los niños bajo riesgo de una insegura afectividad. La función de reflexión de los padres, o sea, lacapacidad de los padres de comprender su propio estado mental y el de sus niños y por tanto regular sus propios sentimientos y conductas hacia su niño, pudiera amortiguar los efectos negativos del estrés tóxico sobre la afectividad. Nuestro objetivo fue probar la eficacia de la intervención Afectividad y Salud del Niño (ATTACH), enfocándonos en mejorar la función de reflexión y la seguridad de la afectividad de los niños, para madres y niños de <36 meses de edad bajo riesgos. Se llevaron a cabo tres estudios pilotos con mujeres y niños de una agencia del centro de la ciudad que les sirve a familias vulnerables de bajos recursos económicos y un albergue para casos de violencia familiar. Un ensayo controlado al azar (n = 20, n = 10 al momento de inscribirse) y métodos cuasi-experimentales (n = 10 al momento de inscribirse) pusieron a prueba el efecto de ATTACH sobre el resultado primario de los puntajes de la función de reflexión, a partir de las transcritas Entrevistas del Desarrollo del Progenitor. Nuestro secundario resultado fueron los patrones de afectividad de los niños con base en el Procedimiento de la Situación Extraña de Ainsworth. A pesar de algunas bajas (n = 2 casos), los análisis de co-variantes con métodos combinados y las pruebas-t revelaron significativas diferencias en la función de reflexión materna, del niño, y en términos generales, con niveles de efectos moderados. Aunque más niños cuyas madres recibieron el programa ATTACH presentaron seguridad en su afectividad después del tratamiento, comparados con el grupo de control, no se observaron diferencias significativas, lo cual pudiera ser consecuencia de observaciones ausentes (n = 5 casos). Comprender la eficacia de programas como ATTACH contribuye a programas y servicios mejorados con el fin de promover un saludable desarrollo de los niños afectados por el estrés tóxico.

Les stresseurs toxiques (par exemple la violence parentale, la dépression, la pauvreté) placement les enfants à risque d'attachement insécure. La fonction parentale de réflexion, c'est-à-dire la capacité des parents à comprendre leurs propres états mentaux et celui de leur enfant et donc de réguler leurs propres sentiments et comportement envers leur enfant, peut servir de tampon aux effets négatifs du stress toxique sur l'attachement. Notre objectif était de tester l'efficacité de l'intervention Attachement et Santé de l'Enfant (en anglais, Attachment and Child Health, soit, ATTACH), en s'attachant à améliorer la fonction de réflexion et la sécurité de l'attachement des enfants, pour des mères à risques et leurs enfants <36 mois d'âge. Trois études pilotes ont été faites avec des femmes et des enfants d'une agence de quartiers défavorisés servant des familles vulnérables, de milieu défavorisé, ainsi qu'un refuge familial pour les victimes de violence. Un essai contrôlé randomisé (n = 20, n = 10 à l'inscription) et des méthodes quasi-expérimentales (n = 10 à l'inscription) ont testé l'effet de ATTACH sur le résultat principal de scores de fonction de réflexion, à partir d'Entretiens du Développement du Parent transcrits. Notre deuxième résultat était les patterns d'attachement des enfants à partir de la Procédure de Situation Etrange d'Ainsworth. En dépit d'une attrition (n = 2 cas), une analyse mixte de la covariance et les tests-t ont révélé des différences importantes dans la fonction de réflexion générale, maternelle, et de l'enfant, avec une ampleur modérée. Alors que plus d'enfants dont les mères ont reçu le programme ATTACH étaient attachés de manière sécure après le traitement, comparés aux contrôles, aucune différence importante n'a été observée, ce qui pourrait s'expliquer par des observations manquantes (n = 5 cas). La compréhension de l'efficacité de programmes comme ATTACH contribue à améliorer des programmes et des services promouvant un développement sain des enfants affectés par le stress toxique.

Effect of the Attachment and Child Health Parent Training Program on Parent-Child Interaction Quality and Child Development.

BACKGROUND: Exposure to chronic stressors (poverty, addiction, family violence) in early life can derail children's development. Interventions focused on parental reflective function may promote parents' abilities to regulate their feelings and behaviors toward their children and buffer the impact of chronic stressors on children's development by nurturing high-quality parent-child interaction. PURPOSE: To test the effectiveness of parental reflective function-focused intervention entitled Attachment and Child Health on parent-child interaction and child development. METHODS: We conducted two pilots with vulnerable mothers and children <36 months. Randomized controlled trial (n = 20) and quasi-experimental (n = 10) methods tested the effect of Attachment and Child Health on parent-child interaction via Parent-Child Interaction Teaching Scale (PCITS) and on child development via Ages and Stages Questionnaire (ASQ-3) and Ages and Stages Questionnaire-Social Emotional (ASQSE). We employed analysis of covariance and t-tests to examine the outcomes. RESULTS: For randomized controlled trial, we found significant improvements in PCITS parent total, combined total, and cognitive growth fostering scores, and ASQ-3 personal-social scores post-intervention. For quasi-experimental study, we found significant improvements in PCITS combined total, sensitivity to cues, response to child's distress, and responsiveness to caregiver scores. CONCLUSION: Incorporating Attachment and Child Health contributed to effective programming for vulnerable families with young children.

Convergent Validity of Three Measures of Reflective Function: Parent Development Interview, Parental Reflective Function Questionnaire, and Reflective Function Questionnaire.

Reflective function (RF) is defined as an individual's ability to understand human behavior in terms of underlying mental states including thoughts, feelings, desires, beliefs, and intentions. More specifically, the capacity of parents to keep their child's mental states in mind is referred to as parental RF. RF has been linked to adult mental health and parental RF to children's mental health and development. The gold standard measure of RF is the interview-based Reflective Functioning Scale (RFS) applied to the Parent Development Interview (PDI) or Adult Attachment Interview (AAI), which while well validated, is time-and labor-intensive to administer. Given the increasing need for reliable, valid, and rapid RF assessment in wide-ranging settings, two alternative measures were considered including the Reflective Function Questionnaire (RFQ) and Parental Reflective Function Questionnaire (PRFQ). We determined the convergent validity of these measures in comparison with the PDI-rated RFS. A sample of mothers and fathers (n = 150) was drawn from a sub-study of the ongoing Alberta Pregnancy Outcomes and Nutrition (APrON) longitudinal cohort when their children were 42-60 months of age. Pearson correlations and multiple linear regression was conducted, followed by splitting the sample to compute Cohen's kappas measures of agreement. Two subscales of the PRFQ correlated significantly (p < 0.05) with the gold standard PDI-rated RFS, providing evidence for convergent validity. As a brief multidimensional measure of parental RF, the PRFQ offers an alternative for measurement of RF in large-scale studies of parental development and child health.

Enhanced physical endurance and improved memory performance following taurine administration in rats.

Energy drinks enhance physical endurance and cognitive ability. The ingredients present in these drinks are considered as ergogenic and have memory boosting effects. In the present study effects of taurine administration for one week was monitored on physical exercise and memory performance in rats. Animals were divided into two groups namely control and test. Taurine was injected intraperitoneally to the test group at the dose of 100mg/kg. After one week of treatment rats were subjected to physical exercise and memory task. Results of this study revealed that rats injected with taurine for one week exhibited improved muscular strength as well as enhanced memory performance in Morris water maze and elevated plus maze. Biomarker of lipid peroxidation was significantly reduced in brain and plasma of test animals. Taurine administration also resulted in higher levels of corticosterone in this study. The results highlight the significance of taurine ingestion in energy demanding and challenging situations in athletes and young subjects.

Attenuation of cadmium-induced decline in spatial, habituation and recognition memory by long-term administration of almond and walnut supplementation: Role of cholinergic function.

Excessive exposure of cadmium which is regarded as a neurotoxin can stimulate aging process by inducing abnormality in neuronal function. It has been reported that supplementation of almond and walnut attenuate age-related memory loss. Present study was designed to investigate the weekly administration of cadmium for one month on learning and memory function with relation to cholinergic activity. Cadmium was administered at the dose of 50 mg/kg/week. Whereas, almond and walnut was supplemented at the dose of 400 mg/kg/day along with cadmium administration to separate set of rats. At the end of experiment, memory function was assessed by Morris water maze, open field test and novel object recognition test. Results of the present study showed that cadmium administration significantly reduced memory retention. Reduced acetylcholine levels and elevated acetyl cholinesterase activity were also observed in frontal cortex and hippocampus of cadmium treated rats. Malondialdehyde levels were also significantly increased following the administration of cadmium. Daily supplementation of almond and walnut for 28 days significantly attenuated cadmium-induced memory impairment in rats. Results of the present study are discussed in term of cholinergic activity in cadmium-induced memory loss and its attenuation by nuts supplementation in rats.

Maternal sensitivity and social support protect against childhood atopic dermatitis.

BACKGROUND: Many studies have identified associations between qualities of maternal-child relationships and childhood asthma, but few have examined associations with childhood atopic dermatitis (AD), a common precursor to asthma. Moreover, maternal psychological distress, including prenatal and postnatal depression, anxiety and stress, may increase risk, while social support from partners may reduce risk for childhood AD. We sought to uncover the association between maternal-infant relationship qualities (maternal sensitivity towards infant behavioral signals, controlling behavior, and unresponsiveness) and child AD after accounting for risk (i.e., prenatal and postnatal maternal depression, anxiety and stress) and protective (i.e., social support) factors. METHODS: We conducted a secondary analysis of data collected on a subsample of 242 women and their infants enrolled during pregnancy in the ongoing Alberta Pregnancy Outcomes and Nutrition cohort study. Inclusion criteria required mothers to be >16 years of age, English speaking and <22 weeks gestational age at enrollment. Data on depression, anxiety and stress in the prenatal and postnatal periods and physician diagnosis of childhood AD at 18 months were gathered via maternal report. Maternal sensitivity, unresponsiveness and controlling behaviours were assessed via videotaped observations using the Child-Adult Relationship Experimental (CARE)-Index at 6 months of infant age. RESULTS: Higher maternal sensitivity, or the inability of the mother to appropriately understand and respond to infant needs based on behavioral signals, predicted reduced odds of AD independent of and in combination with low prenatal and postnatal anxiety and high paternal support. After adjustment, higher maternal controlling behaviours and unresponsiveness also predicted greater odds of AD. CONCLUSIONS: Low maternal sensitivity is a risk factor for childhood AD, independently and in combination with perinatal anxiety and low social support. Thus, interventions that improve maternal-infant relationship quality, especially sensitivity, reduce anxiety and improve social support from partners could reduce odds of childhood AD.

Magnesium treatment palliates noise-induced behavioral deficits by normalizing DAergic and 5-HTergic metabolism in adult male rats.

Magnesium (Mg) is the fourth most abundant biological mineral essential for good health. Neuroprotective, anxiolytic and antidepressant effects of magnesium following stress and brain injuries are well established. In present study, we analyzed the protective effects of magnesium in rats exposed to sub-chronic noise stress. Magnesium Chloride (MgCl2, 100 mg/kg) was administered intraperitoneally once daily for 15 days prior exposure to noise stress. Rats were exposed to noise stress for 4 h after administration of magnesium for 15 days. At the end of treatment behavioral alterations were assessed. Animals were decapitated following behavioral testing and the brains were dissected out for neurochemical estimations by HPLC-EC. Improvement in noise-induced memory deficits as assessed by novel object recognition (NOR) test and elevated plus maze (EPM) test was found in magnesium treated rats. This improvement in noise-induced behavioral deficits following treatment with magnesium may be attributed to a significant decrease (p < 0.01) in dopamine (DA) and serotonin (5-hydroxytryptamine; 5-HT) turnover as compared to control rats observed in present work. These results suggest that treatment with magnesium can attenuate the noise-induced deficits and may be used as a therapy against noise-induced neurodegeneration. Moreover an adequate amount of magnesium in daily diet may help to develop the ability to resist against or cope up with stressful conditions encountered in daily life.

Short term cadmium administration dose dependently elicits immediate biochemical, neurochemical and neurobehavioral dysfunction in male rats.

Cadmium is a toxic environmental and industrial pollutant. Cadmium toxicity has been reported to produce biochemical and behavioral dysfunction that may cause adverse effects on several organs including the central nervous system. The present study was designed to investigate the neurotoxic effects of Cadmium Chloride (CdCl2) at three different doses by using different behavioral models. Lipid peroxidation (LPO), superoxide dismutase (SOD) and acetylcholinesterase (AChE) activities were also monitored following acute intraperitoneal injection of cadmium. Twenty four adult locally bred Albino Wistar rats were divided into control and 3 test groups (n = 6). Control rats were injected intraperitoneally with saline (0.9% NaCl) and test groups were injected with CdCl2 (1 mg/kg, 2 mg/kg and 3 mg/kg) dissolved in physiological solution. Behavioral activities of rats were monitored after 1 h of cadmium injection. Locomotor activity and depression-like symptoms were measured by Open Field Test (OFT) and Forced Swimming Test (FST) respectively. Anxiety like behavior was monitored using Light-dark Transition (LDT) test and memory functions of rats were assessed by Morris Water Maze test (MWM). In the present study acute cadmium administration dose dependently increased anxiety in rats as compared to control rats. A significant increase in depression-like symptoms was also exhibited by cadmium treated rats. These behavioral dysfunctions may be attributed to the decreased superoxide dismutase (SOD) activity and simultaneously increased brain lipid peroxidation (LPO). Moreover learning and memory assessed by MWM showed dose dependent impairment in memory function in cadmium treated rats as compared to control rats. Acetylcholinesterase (AChE) activity was also decreased in brains of cadmium administered rats. It is suggested in this study that behavioral, biochemical and neurochemical dysfunctions caused by acute cadmium administration occur in a dose dependent manner.

The most effective strategy for recruiting a pregnancy cohort: a tale of two cities.

BACKGROUND: Pregnant women were recruited into the Alberta Pregnancy Outcomes and Nutrition (APrON) study in two cities in Alberta, Calgary and Edmonton. In Calgary, a larger proportion of women obtain obstetrical care from family physicians than from obstetricians; otherwise the cities have similar characteristics. Despite similarities of the cities, the recruitment success was very different. The purpose of this paper is to describe recruitment strategies, determine which were most successful and discuss reasons for the different success rates between the two cities. METHODS: Recruitment methods in both cities involved approaching pregnant women (< 27 weeks gestation) through the waiting rooms of physician offices, distributing posters and pamphlets, word of mouth, media, and the Internet. RESULTS: Between May 2009 and November 2010, 1,200 participants were recruited, 86% (1,028/1,200) from Calgary and 14% (172/1,200) from Edmonton, two cities with similar demographics. The most effective strategy overall involved face-to-face recruitment through clinics in physician and ultrasound offices with access to a large volume of women in early pregnancy. This method was most economical when clinic staff received an honorarium to discuss the study with patients and forward contact information to the research team. CONCLUSION: Recruiting a pregnancy cohort face-to-face through physician offices was the most effective method in both cities and a new critically important finding is that employing this method is only feasible in large volume maternity clinics. The proportion of family physicians providing antenatal and post-natal care may impact recruitment success and should be studied further.