Risk of Cesarean Delivery Among People With Inflammatory Bowel Disease According to Disease Characteristics: A Population-Based Study.

OBJECTIVES: It is unclear if use of cesarean delivery in people with inflammatory bowel disease (IBD) is guideline-concordant. We compared the odds of cesarean delivery among primiparous individuals with IBD versus without, overall, and by disease characteristics, as well as time to subsequent delivery. METHODS: Retrospective matched population-based cohort study between 1 April 1994 and 31 March 2020. Primiparous individuals aged 15-55 years with IBD were matched to those without IBD on age, year, hospital, and number of newborns delivered. Primary outcome was cesarean delivery versus vaginal delivery. Multivariable conditional logistic regression analyses were performed to estimate the odds of cesarean delivery among individuals with and without IBD as a binary exposure, and a categorical exposure based on IBD-related indications for cesarean delivery. Time to subsequent delivery was evaluated using a Cox proportional hazard model. RESULTS: We matched 7472 individuals with IBD to 37 360 individuals without (99.02% match rate). Individuals with IBD were categorised as having perianal (PA) disease (IBD-PA, n = 764, 10.2%), prior ileal pouch-anal anastomosis (n = 212, 2.8%), or IBD-Other (n = 6496, 86.9%). Cesarean delivery rates were 35.4% in the IBD group versus 30.4% in their controls (adjusted odds ratio 1.27; 95% CI 1.20-1.34). IBD-ileal pouch-anal anastomosis had a cesarean delivery rate of 66.5%, compared to 49.9% in IBD-PA and 32.7% in IBD-Other. There was no significant difference in the rate of subsequent delivery in those with and without IBD (adjusted hazard ratio 1.03,;95% CI 1-1.07). CONCLUSIONS: The higher risk of cesarean delivery in people with IBD reflects guideline-concordant use. Individuals with and without IBD were equally likely to have a subsequent delivery with similar timing.

Strategies to support maternal and early childhood wellness: insight from parent and provider qualitative interviews during the COVID-19 pandemic.

OBJECTIVES: The COVID-19 pandemic resulted in rapid changes to the delivery of maternal and newborn care. Our aim was to gain an understanding from parents and healthcare professionals (HCPs) of how the pandemic and associated public health restrictions impacted the peripartum and postpartum experience, as well as longer-term health and well-being of families. DESIGN: Qualitative study through focus groups. SETTING: Ontario, Canada. PARTICIPANTS: HCPs and parents who had a child born during the COVID-19 pandemic. INTERVENTIONS: Semistructured interview guide, with questions focused on how the pandemic impacted their care/their ability to provide care, and strategies to improve care and support now or in future situations with similar healthcare restrictions. OUTCOME MEASURES: Thematic analysis was used to describe participant experiences and recommendations. RESULTS: We included 11 HCPs and 15 parents in 6 focus groups. Participants described their experiences as 'traumatic', with difficulties in accessing prenatal and postpartum services, and feelings of distress and isolation. They also noted delays in speech and development in children born during the pandemic. Key recommendations included the provision of partner accompaniment throughout the course of care, expansion of available services for young families (particularly postpartum), and special considerations for marginalised groups, including access to technology for virtual care or the option of in-person visits. CONCLUSIONS: Our findings may inform the development of healthcare system and organisational policies to ensure the provision of maternal and newborn care in the event of future public health emergencies. Of primary importance to the participants was the accommodation of antenatal, intrapartum and postpartum partner accompaniment, and the provision of postpartum services.

Medical Students' Perspectives on Family Planning and Impact on Specialty Choice.

Importance: Physicians are known to delay childbearing compared with nonphysicians and to experience higher rates of age-related pregnancy complications. Delay of childbearing is more pronounced in surgical specialties, and family planning and building goals may influence specialty choice. Objective: To assess medical students' perspectives on the development of family planning goals and the timing of family building within a medical career to elucidate how these perceptions impact their choice of specialty. Design, Setting, and Participants: This qualitative study included fourth-year medical students at the University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada, and was conducted between May and August 2021. Participants were purposively sampled to maximize diversity of gender and specialty choice. Interviews were conducted via videoconferencing software that were recorded, transcribed verbatim, and verified for accuracy. Thematic analysis was completed independently by 2 researchers and consensus on final themes was reached through discussion among study investigators. Data were analyzed between September and December 2021. Main Outcomes and Measures: Participants were asked to share their perceptions of personal family planning goals, support currently in place, family planning education in medicine and factors contributing to their choice of specialty and program. Thematic analysis was completed. Results: A total of 34 fourth-year medical students (median [range] age, 26 [24-33] years; 23 females [67.6%]) were interviewed. Four main themes were identified: (1) there is no ideal time to family build in a medical career, (2) family planning is a taboo topic, (3) surgical specialties offer less support for family building, and (4) residents who have children are perceived to place a burden on their colleagues. Medical students considered their family planning while deliberating among specialty choices and their experiences were highly influential in shaping their specialty selection. Conclusions and Relevance: Results of this qualitative study suggest that medical students perceive that family building during training may have unfavorable implications for team dynamics and relationships with colleagues, and these perceptions may affect specialty choice and family planning goals. Integration of family planning discussions and support for family building into medical curricula is needed along with efforts to improve culture by supporting team dynamics and workload when students take parental leave.

A Population-Based Test-Negative Matched Case-Control Analysis of SARS-CoV-2 Vaccine Effectiveness Among Pregnant People in Ontario, Canada.

OBJECTIVE: Pregnancy is a risk factor for severe SARS-CoV-2 infection, which can result in adverse pregnancy outcomes, thus making understanding vaccine effectiveness (VE) in this population important. This study aimed to assess the VE of mRNA COVID-19 vaccines against symptomatic SARS-CoV-2 infection and COVID-19-related hospitalization in pregnant people. METHODS: Population-based matched test-negative case-control study of pregnant people aged 18-49 years, of 12 or more weeks gestation in Ontario, Canada, symptomatic with possible SARS-CoV-2 infection, and having at least 1 positive (n = 1842) or negative (n = 8524) real-time polymerase chain reaction (RT-PCR) SARS-CoV-2 test between December 14, 2020, and December 31, 2021. The exposure was receipt of ≥1 dose of mRNA COVID-19 vaccine versus no vaccination. Exposure was further stratified by number and recency of doses. The primary outcome was a positive SARS-CoV-2 RT-PCR test. As a secondary outcome, VE for COVID-19-related hospitalization was assessed. RESULTS: In the primary outcome analysis, there were 1821 positive cases, matched to 1821 negative controls. The mean (SD) maternal age was 31 (5) years. When compared to those unvaccinated, receipt of ≥1 dose was associated with an estimated VE of 39% (95% CI 29%-48%) for symptomatic infection, and 85% (95% CI 72%-92%) for COVID-19 hospitalization. VE estimates demonstrated waning with increased time since last vaccination. CONCLUSIONS: mRNA COVID-19 vaccines provide protection against symptomatic COVID-19 illness and are highly effective at preventing severe illness in pregnant people. The observed effect of vaccine waning highlights the importance of booster doses to provide optimal protection for pregnant people.

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

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

Patient, family and professional suggestions for pandemic-related surgical backlog recovery: a qualitative study.

BACKGROUND: Surgical shutdowns related to the COVID-19 pandemic have resulted in prolonged wait times for nonemergency surgery. We aimed to understand informational needs and generate suggestions on management of the surgical backlog in the context of the ongoing COVID-19 pandemic through focus groups with key stakeholders. METHODS: We performed a qualitative study with focus groups held between Sept. 29 and Nov. 30, 2021, in Ontario, with patients who underwent or were awaiting surgery during the pandemic and their family members, and health care leaders with experience or influence overseeing the delivery of surgical services. We conducted the focus groups virtually; focus groups for patients and family members were conducted separately from health care leaders to ensure participants could speak freely about their experiences. Our goal was to elicit information on the impact of communication about the surgical backlog, how this communication may be improved, and to generate and prioritize suggestions to address the backlog. Data were mapped onto 2 complementary frameworks that categorized approaches to reduction in wait times and strategies to improve health care delivery. RESULTS: A total of 11 patients and family members and 20 health care leaders (7 nursing surgical directors, 10 surgeons and 3 administrators) participated in 7 focus groups (2 patient and family, and 5 health care leader). Participants reported receiving conflicting information about the surgical backlog. Suggestions for communication about the backlog included unified messaging from a single source with clear language to educate the public. Participants prioritized the following suggestions for surgical recovery: increase supply through focusing on system efficiencies and maintaining or increasing health care personnel; incorporate patient-centred outcomes into triage definitions; and refine strategies for performance management to understand and measure inequities between surgeons and centres, and consider the impact of funding incentives on "nonpriority" procedures. INTERPRETATION: Patients and their families and health care leaders experienced a lack of communication about the surgical backlog and suggested this information should come from a single source; key suggestions to manage the surgical backlog included a focus on system efficiencies, incorporation of patient-centred outcomes into triage definitions, and improving the measurement of wait times to monitor health system performance. The suggestions generated in this study that may be used to address surgical backlog recovery in the Canadian setting.

Characterizing the Impact of Procedure Funding on the Covid-19 Generated Procedure Gap in Ontario: A Population-Based Analysis.

BACKGROUND: Surgical procedures in Canada were historically funded through global hospital budgets. Activity-based funding models were developed to improve access, equity, timeliness, and value of care for priority areas. COVID-19 upended health priorities and resulted in unprecedented disruptions to surgical care, which created a significant procedure gap. We hypothesized that activity-based funding models influenced the magnitude and trajectory of this procedure gap. METHODS: Population-based analysis of procedure rates comparing the pandemic (March 1, 2020-December 31, 2021) to a prepandemic baseline (January 1, 2017-February 29, 2020) in Ontario, Canada. Poisson generalized estimating equation models were used to predict expected rates in the pandemic based on the prepandemic baseline. Analyses were stratified by procedure type (outpatient, inpatient), body region, and funding category (activity-based funding programs vs. global budget). RESULTS: In all, 281,328 fewer scheduled procedures were performed during the COVID-19 period compared with the prepandemic baseline (Rate Ratio 0.78; 95% CI 0.77-0.80). Inpatient procedures saw a larger reduction (24.8%) in volume compared with outpatient procedures (20.5%). An increase in the proportion of procedures funded through activity-based programs was seen during the pandemic (52%) relative to the prepandemic baseline (50%). Body systems funded predominantly through global hospital budgets (eg, gynecology, otologic surgery) saw the least months at or above baseline volumes, whereas those with multiple activity-based funding options (eg, musculoskeletal, abdominal) saw the most months at or above baseline volumes. CONCLUSIONS: Those needing procedures funded through global hospital budgets may have been disproportionately disadvantaged by pandemic-related health care disruptions.

Cannabis use among pregnant women under different legalization frameworks in the United States.

Background: Cannabis use in pregnancy is associated with adverse neonatal outcomes, yet its use among pregnant women in the United States has increased significantly.Objectives: This cross-sectional study explored how cannabis use in pregnant women varied between different cannabis legalization frameworks, that is, permitted use of cannabidiol (CBD)-only, medical cannabis, and adult-use cannabis.Methods: Behavioral Risk Factor Surveillance System data from 2017 to 2020 was utilized with respondents classified by their state's policies into CBD-only, medical, and adult-use groups. Outcome measures included prevalence of use and usage characteristics (frequency, method of intake, and reason for use) among pregnant women. Logistic regression models were estimated to evaluate the association between legal status and prevalence of use.Results: The unweighted dataset included 1,992 pregnant women. Recent cannabis use was reported by (weighted proportions): 2.4% (95%CI: 0-4.4) of respondents in the CBD-only group, 7.1% (95%CI: 4.0-10.1) in the medical group and 6.9% (95%CI: 3.0-10.9) in the adult-use group. Compared to the CBD-only group, respondents in the medical and adult-use groups were 4.5-fold (adjusted; 95%CI: 1.4-14.7; p = .01) and 4.7-fold (adjusted; 95%CI: 1.3-16.2; p = .02) more likely to use cannabis. Across all groups, smoking was the most common method of intake and over 49% of users reported using partially or entirely for adult-use purposes.Conclusions: The increased use with legalization motivates further research on the impacts of cannabis as a therapeutic agent during pregnancy and supports the need for increased screening and patient counseling regarding the potential effects of cannabis use on fetal development.

Evaluation of Adverse Pregnancy Outcomes in Physicians Compared With Nonphysicians.

Importance: Physicians may be at risk of pregnancy complications due to prolonged work hours, overnight shifts, occupational hazards, and older maternal age at first birth compared with nonphysicians. Observational studies of physicians, including comparisons across physician specialties, are needed. Objective: To compare adverse maternal and perinatal outcomes between pregnant physicians and nonphysicians and between physicians of different specialties. Design, Setting, and Participants: A population-based retrospective cohort study was conducted in Ontario, Canada. Participants included physicians and nonphysician comparators residing in high-income areas who experienced a birth at 20 or more weeks' gestation from April 1, 2002, to November 26, 2018. Data analysis was performed from December 2020 to March 2022. Exposures: Physician occupation and physician specialty. Main Outcomes and Measures: Severe maternal morbidity (in pregnancy and up to 42 days' post partum) and severe neonatal morbidity (up to hospital discharge among live-born infants) were the primary outcomes. Logistic regression under a generalized estimating equations approach was used to compare outcomes between physicians and nonphysicians, accounting for potentially more than 1 pregnancy per woman. Odds ratios were adjusted (aOR) for maternal age, parity, previous preterm birth, calendar year, immigration status, comorbidities, multiple gestation, and mode of delivery. Results: A total of 10 489 births occurred among 6161 licensed physicians, and 298 683 births occurred among 211 191 nonphysician counterparts. Physicians were older (median [IQR] age, 34 [31-36] vs 32 [29-35] years) and more likely to be nulliparous (5049 [48.1%] vs 128 961 [43.2%]) compared with nonphysicians. Severe maternal morbidity was more likely to occur among physicians than nonphysicians (unadjusted OR, 1.21; 95% CI, 1.04-1.41) but not after adjusting for study covariates (aOR, 1.13; 95% CI, 0.97-1.32). Severe neonatal morbidity was less likely to occur among infants of physicians than infants of nonphysicians (aOR, 0.79; 95% CI, 0.72-0.87). Compared with family physicians, neither nonsurgical specialists (aOR, 1.12; 95% CI, 0.82-1.53) nor surgical specialists (aOR, 1.43; 95% CI, 0.74-2.76) were at increased risk of severe maternal morbidity. Similar findings were observed for severe neonatal morbidity (nonsurgical specialists: aOR, 0.98; 95% CI, 0.80-1.19; surgical specialists: aOR, 1.08; 95% CI, 0.68-1.71). Conclusions and Relevance: The findings of this study suggest that female physicians may be at slightly higher risk of severe maternal morbidity. This association appeared to be mediated by their tendency to delay childbearing compared with nonphysicians. Newborns of physicians appear to experience less morbidity. Such differences were not observed between physician specialty groups.

Preeclampsia and Severe Maternal Morbidity During the COVID-19 Pandemic: A Population-Based Cohort Study in Ontario, Canada.

OBJECTIVE: Significant changes to the delivery of obstetrical care that occurred with the onset of the COVID-19 pandemic may be associated with higher risks of adverse maternal outcomes. We evaluated preeclampsia/HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome and composite severe maternal morbidity (SMM) among pregnant people who gave birth during the COVID-19 pandemic and compared these data with those of people who gave birth before the pandemic in Ontario, Canada. METHODS: This was a population-based, retrospective cohort study using linked administrative data sets from ICES. Data on pregnant people at ≥20 weeks gestation who gave birth between March 15, 2020, and September 30, 2021, were compared with those of pregnant people who gave birth within the same date range for the years 2015-2019. We used multivariable logistic regression to assess the effect of the pandemic period on the odds of preeclampsia/HELLP syndrome and composite SMM, adjusting for maternal baseline characteristics and comorbidities. RESULTS: There were no differences between the study periods in the adjusted odds ratios (aORs) for preeclampsia/HELLP syndrome among primiparous (aOR 1.00; 95% CI 0.91-1.11) and multiparous (aOR 0.94; 95% CI 0.81-1.09) patients and no differences for composite SMM (primiparous, aOR 1.00; 95% CI 0.95-1.05; multiparous, aOR 1.01; 95% CI 0.95-1.08). CONCLUSION: Adverse maternal outcomes were not higher among pregnant people who gave birth during the first 18 months of the COVID-19 pandemic in Ontario, Canada, when compared with those who gave birth before the pandemic.

Sex Differences in the Pattern of Patient Referrals to Male and Female Surgeons.

Importance: Studies have found that female surgeons have fewer opportunities to perform highly remunerated operations, a circumstance that contributes to the sex-based pay gap in surgery. Procedures performed by surgeons are, in part, determined by the referrals they receive. In the US and Canada, most practicing physicians who provide referrals are men. Whether there are sex-based differences in surgical referrals is unknown. Objective: To examine whether physicians' referrals to surgeons are influenced by the sex of the referring physician and/or surgeon. Design, Setting, and Participants: This cross-sectional, population-based study used administrative databases to identify outpatient referrals to surgeons in Ontario, Canada, from January 1, 1997, to December 31, 2016, with follow-up to December 31, 2018. Data analysis was performed from April 7, 2019, to May 14, 2021. Exposures: Referring physician sex. Main Outcomes and Measures: This study compared the proportion of referrals (overall and those referrals that led to surgery) made by male and female physicians to male and female surgeons to assess associations between surgeon, referring physician, or patient characteristics and referral decisions. Discrete choice modeling was used to examine the extent to which sex differences in referrals were associated with physicians' preferences for same-sex surgeons. Results: A total of 39 710 784 referrals were made by 44 893 physicians (27 792 [61.9%] male) to 5660 surgeons (4389 [77.5%] male). Female patients made up a greater proportion of referrals to female surgeons than to male surgeons (76.8% vs 55.3%, P < .001). Male surgeons accounted for 77.5% of all surgeons but received 87.1% of referrals from male physicians and 79.3% of referrals from female physicians. Female surgeons less commonly received procedural referrals than male surgeons (25.4% vs 33.0%, P < .001). After adjusting for patient and referring physician characteristics, male physicians referred a greater proportion of patients to male surgeons than did female physicians; differences were greatest among referrals from other surgeons (rate ratio, 1.14; 95% CI, 1.13-1.16). Female physicians had a 1.6% (95% CI, 1.4%-1.9%) greater odds of same-sex referrals, whereas male physicians had a 32.0% (95% CI, 31.8%-32.2%) greater odds of same-sex referrals; differences did not attenuate over time. Conclusions and Relevance: In this cross-sectional, population-based study, male physicians appeared to have referral preferences for male surgeons; this disparity is not narrowing over time or as more women enter surgery. Such preferences lead to lower volumes of and fewer operative referrals to female surgeons and are associated with sex-based inequities in medicine.

A population-based analysis of the impact of the COVID-19 pandemic on common abdominal and gynecological emergency department visits.

BACKGROUND: Reduced use of the emergency department during the COVID-19 pandemic may result in increased disease acuity when patients do seek health care services. We sought to evaluate emergency department visits for common abdominal and gynecologic conditions before and at the beginning of the pandemic to determine whether changes in emergency department attendance had serious consequences for patients. METHODS: We conducted a population-based analysis using administrative data to evaluate the weekly rate of emergency department visits pre-COVID-19 (Jan. 1-Mar. 10, 2020) and during the beginning of the COVID-19 pandemic (Mar. 11-June 30, 2020), compared with a historical control period (Jan. 1-July 1, 2019). All residents of Ontario, Canada, presenting to the emergency department with appendicitis, cholecystitis, ectopic pregnancy or miscarriage were included. We evaluated weekly incidence rate ratios (IRRs) of emergency department visits, management strategies and clinical outcomes. RESULTS: Across all study periods, 39 691 emergency department visits met inclusion criteria (40.2 % appendicitis, 32.1% miscarriage, 21.3% cholecystitis, 6.4% ectopic pregnancy). Baseline characteristics of patients presenting to the emergency department did not vary across study periods. After an initial reduction in emergency department visits, presentations for cholecystitis and ectopic pregnancy quickly returned to expected levels. However, presentations for appendicitis and miscarriage showed sustained reductions (IRR 0.61-0.80), with 1087 and 984 fewer visits, respectively, after the start of the pandemic, relative to 2019. Management strategies, complications and mortality rates were similar across study periods for all conditions. INTERPRETATION: Although our study showed evidence of emergency department avoidance in Ontario during the first wave of the COVID-19 pandemic, no adverse consequences were evident. Emergency care and outcomes for patients were similar before and during the pandemic.