Teen Pregnancy and Risk of Premature Mortality.

Importance: Unintentional injury, suicide, and homicide are leading causes of death among young females. Teen pregnancy may be a marker of adverse life experiences. Objective: To evaluate the risk of premature mortality from 12 years of age onward in association with number of teen pregnancies and age at pregnancy. Design, Setting, and Participants: This population-based cohort study was conducted among all females alive at 12 years of age from April 1, 1991, to March 31, 2021, in Ontario, Canada (the most populous province, which has universal health care and data collection). The study period ended March 31, 2022. Exposures: The main exposure was number of teen pregnancies between 12 and 19 years of age (0, 1, or ≥2). Secondary exposures included how the teen pregnancy ended (birth or miscarriage vs induced abortion) and age at first teen pregnancy. Main Outcomes and Measures: The main outcome was all-cause mortality starting at 12 years of age. Hazard ratios (HRs) were adjusted for year of birth, comorbidities at 9 to 11 years of age, and area-level education, income level, and rurality. Results: Of 2 242 929 teenagers, 163 124 (7.3%) experienced a pregnancy at a median age of 18 years (IQR, 17-19 years). Of those with a teen pregnancy, 60 037 (36.8%) ended in a birth (of which 59 485 [99.1%] were live births), and 106 135 (65.1%) ended in induced abortion. The median age at the end of follow-up was 25 years (IQR, 18-32 years) for those without a teen pregnancy and 31 years (IQR, 25-36 years) for those with a teen pregnancy. There were 6030 deaths (1.9 per 10 000 person-years [95% CI, 1.9-2.0 per 10 000 person-years]) among those without a teen pregnancy, 701 deaths (4.1 per 10 000 person-years [95% CI, 3.8-4.5 per 10 000 person-years]) among those with 1 teen pregnancy, and 345 deaths (6.1 per 10 000 person-years [95% CI, 5.5-6.8 per 10 000 person-years]) among those with 2 or more teen pregnancies; adjusted HRs (AHRs) were 1.51 (95% CI, 1.39-1.63) for those with 1 pregnancy and 2.14 (95% CI, 1.92-2.39) for those with 2 or more pregnancies. Comparing those with vs without a teen pregnancy, the AHR for premature death was 1.25 (95% CI, 1.12-1.40) from noninjury, 2.06 (95% CI, 1.75-2.43) from unintentional injury, and 2.02 (95% CI, 1.54-2.65) from intentional injury. Conclusions and Relevance: In this population-based cohort study of 2.2 million female teenagers, teen pregnancy was associated with future premature mortality. It should be assessed whether supports for female teenagers who experience a pregnancy can enhance the prevention of subsequent premature mortality in young and middle adulthood.

Sexual and Reproductive Health Outcomes Among Adolescent Females During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Coronavirus disease 2019 (COVID-19) posed a significant threat to adolescents' sexual and reproductive health. In this study, we examined population-level pregnancy and sexual health-related care utilization among adolescent females in Ontario, Canada during the pandemic and evaluated relationships between these outcomes and key sociodemographic characteristics. METHODS: This was a population-based, repeated cross-sectional study of >630 000 female adolescents (12-19 years) during the prepandemic (January 1, 2018-February 29, 2020) and COVID-19 pandemic (March 1, 2020-December 31, 2022) periods. Primary outcome was pregnancy; secondary outcomes were contraceptive management visits, contraception prescription uptake, and sexually transmitted infection (STI) management visits. Poisson models with generalized estimating equations for clustered count data were used to model pre-COVID-19 trends and forecast expected rates during the COVID-19 period. Absolute rate differences between observed and expected outcome rates for each pandemic month were calculated overall and by urbanicity, neighborhood income, immigration status, and region. RESULTS: During the pandemic, lower-than-expected population-level rates of adolescent pregnancy (rate ratio 0.87; 95% confidence interval [CI]:0.85-0.88), and encounters for contraceptive (rate ratio 0.82; 95% CI:0.77-0.88) and STI management (rate ratio 0.52; 95% CI:0.51-0.53) were observed. Encounter rates did not return to pre-pandemic rates by study period end, despite health system reopening. Pregnancy rates among adolescent subpopulations with the highest pre-pandemic pregnancy rates changed least during the pandemic. CONCLUSIONS: Population-level rates of adolescent pregnancy and sexual health-related care utilization were lower than expected during the COVID-19 pandemic, and below-expected care utilization rates persist. Pregnancy rates among more structurally vulnerable adolescents demonstrated less decline, suggesting exacerbation of preexisting inequities.

Pathways to Care for Adolescents Attending a First Hormone Appointment at Canadian Gender Affirming Medical Clinics: A Cross-Sectional Analysis From the Trans Youth CAN! Study.

PURPOSE: Limited research has examined adolescents' pathways to gender-affirming medical care. METHODS: Enrollment in Trans Youth CAN! was at an initial appointment for hormone suppression or gender-affirming hormones, if pubertal or postpubertal, and < 16 years old. Adolescent/parent surveys and clinical records were obtained for 174 adolescents and 160 matched parents at 10 medical clinics across Canada. RESULTS: Participants' mean age was 14.3 years, 95% confidence interval (CI) [14.1-14.6]; 126 (75.8%) identified as boys, 32 (15.9%) girls, and 14 (8.3%) nonbinary. Average wait time after referral was 269 days (95% CI [244, 294]). Adolescents reported 13.5 months seeking gender-affirming medical care, longer than reported by their parents (p = .0001). Family physicians or pediatricians provided 68% of referrals. Prior to clinic, adolescents saw an average of 2.7 (maximum eight) different types of providers (95% CI [2.4, 2.9]). Indigenous background and greater number of types of providers seen were associated with longer time seeking care. The majority of adolescents had ever engaged in self-harm (67.6%), with 58.1% ever seriously considering suicide and 36.0% attempting. Previous self-harm and suicidal thoughts were associated with longer wait times and older age. Seventeen point seven percent of parents/caregivers reported their adolescents had participated in conversion therapy or that parents had considered it. DISCUSSION: The majority of participants were referred by family physicians or pediatricians, seeing multiple types of providers regarding their gender prior to referral. Adolescents experienced significant wait times. Indigenous adolescents reported longer times seeking care. Adolescents with longer wait times were more likely to have ever engaged in self-harm or had suicidal ideation.

An affirming approach to caring for transgender and gender-diverse youth.

Increasing numbers of youth identify as transgender or gender-diverse (TGD). Many paediatricians and primary care providers (PCPs) will encounter this population in their practice, either for gender-related care or general health needs. This statement is intended as a resource to guide paediatricians and PCPs in implementing an affirming approach to routine health care provision for all youth. Furthermore, it presents information to assist providers in responding to requests for counselling from TGD youth and their families around potential options for medical transition, and in making referrals to specialized services, if desired and relevant. Finally, as demand for gender-affirming care is anticipated to continue to increase, some health care providers (HCPs) may wish to develop the knowledge and skills required to initiate adolescents on hormone-blocking agents and gender-affirming hormones. This document is not intended to be a clinical practice guideline, but will provide foundational information regarding these potential components of gender-affirming care, recognizing that the needs and goals of individual adolescents may or may not include such interventions. Additional resources relevant to developing the expertise required to provide gender-affirming interventions will also be identified.

Une approche d'affirmation pour les soins aux jeunes transgenres et de diverses identités de genre.

Un nombre croissant de jeunes s'identifient comme transgenres ou de diverses identités de genre. De nombreux pédiatres et dispensateurs de soins de première ligne accueilleront cette population dans leur pratique, dans le cadre de soins liés au genre ou de soins de santé généraux. Le présent document de principes se veut une ressource pour orienter les pédiatres et les dispensateurs de soins de première ligne à adopter une approche d'affirmation pour la prestation des soins réguliers à tous les jeunes. De plus, il contient de l'information visant à aider les dispensateurs à répondre aux demandes de conseils des jeunes transgenres et de diverses identités de genre et de leur famille au sujet des possibilités de transition médicale et d'orientation vers des services spécialisés s'ils le désirent et le jugent pertinent. Enfin, on anticipe que la demande de soins d'affirmation de genre continue d'augmenter, et certains dispensateurs de soins peuvent souhaiter acquérir les connaissances et les habiletés nécessaires pour amorcer les inhibiteurs d'hormones et les hormones d'affirmation de genre chez les adolescents. Le présent document ne contient pas de directives cliniques, mais de l'information fondamentale au sujet des divers éléments possibles des soins d'affirmation de genre, tout en reconnaissant que les besoins et les objectifs d'adolescents particuliers n'incluent pas automatiquement de telles interventions. D'autres ressources permettant d'acquérir les compétences nécessaires pour offrir des interventions d'affirmation de genre sont également proposées.

Association of maternal risk factors with infant maltreatment: an administrative data cohort study.

OBJECTIVE: We aimed to evaluate the risk of infant maltreatment associated with commonly used criteria for home visiting programmes: young maternal age, maternal adversity (homelessness, substance abuse, intimate partner violence), newcomer status and mental health concerns in Ontario, Canada. DESIGN: This retrospective cohort study included infants born in hospital in Ontario from 1 April 2005 to 31 March 2017 captured in linked health administrative and demographic databases. Infants were followed from newborn hospitalisation until 1 year of age for child maltreatment captured in healthcare or death records. The association between type and number of maternal risk factors, and maltreatment, was analysed using multivariable logistic regression modelling, controlling for infant characteristics and material deprivation. Further modelling explored the association of each year of maternal age with maltreatment. RESULTS: Of 989 586 infants, 434 (0.04%) had recorded maltreatment. Maternal age <22 years conferred higher risk of infant maltreatment (adjusted OR (aOR) 5.5, 95% CI 4.5 to 6.8) compared with age ≥22 years. Maternal mental health diagnoses (aOR 2.0, 95% CI 1.6 to 2.5) were also associated with maltreatment, while refugee status appeared protective (aOR 0.6, 95% CI 0.4 to 1.0). The odds of maltreatment increased with higher numbers of maternal risk factors. Maternal age was associated with maltreatment until age 28 years. CONCLUSION: Infants born to young mothers are at greater risk of infant maltreatment, and this association remained until age 28 years. These findings are important for ensuring public health interventions are supporting populations experiencing structural vulnerabilities with the aim of preventing maltreatment.

Understanding the roles of the healthcare and child welfare systems in promoting the safety and well-being of children.

Introduction: The accurate identification and appropriate investigation of child maltreatment is a key priority for promoting the optimal health and development of children. Healthcare providers are often well-positioned professionals to report suspected child abuse and neglect, and, therefore, interact regularly with child welfare workers. Little research has examined the relationship between these two groups of professionals. Methods: We interviewed healthcare providers and child welfare workers in order to examine the referral and child welfare investigation processes to understand strengths and identify areas of improvement for future collaboration. Thirteen child welfare workers from child welfare agencies and eight healthcare providers from a pediatric tertiary care hospital in Ontario, Canada were interviewed to meet the study's objectives. Results: Healthcare providers spoke about positive experiences making reports, factors impacting reporting decisions, areas for improvement (e.g., difficulties communicating, lack of collaboration, and disruption of therapeutic alliance), training, and professional roles. For interviews with child welfare workers, identified themes included healthcare professionals' perceived expertise and understanding the role of child welfare. Both groups brought up the need for increased collaboration as well as systemic barriers and legacies of harm. Discussion: Our core finding was a reported lack of communication between the groups of professionals. Other identified barriers in collaboration included a lack of understanding of each other's roles, hesitation for healthcare providers making reports, as well as legacies of harm and systemic inequities in both institutions. Future research should build on this examination by including the voices of healthcare providers and child welfare workers to identify sustainable solutions for increased collaboration.

Perspectives on COVID-19 Vaccination and Vaccine Passports in a Diverse Urban Adolescent Population: A Youth Participatory Mixed Methods Study.

PURPOSE: Disparities in youth COVID-19 vaccine acceptance and uptake have been documented in several countries, yet few studies have explored the attitudes and perceptions underlying vaccine-related decision-making among adolescent populations with unique sociocultural, environmental, and/or structural contexts that may influence vaccine uptake. METHODS: This study used data from surveys and semistructured interviews collected between January and March 2022 as part of an ongoing community-based research project in two ethnoculturally diverse, lower income neighborhoods of Montreal, Canada. Youth researchers designed and conducted interviews with unvaccinated adolescents, and thematic analysis was employed to explore attitudes and perceptions underlying vaccine-related decisions and opinions about vaccine passports. Survey data were used to describe sociodemographic and psychological determinants of COVID-19 vaccination. RESULTS: Among 315 survey participants aged 14-17 years, most (74%) were fully vaccinated against COVID-19. Prevalence ranged from 57% among Black adolescents to 91% among South and/or Southeast Asian adolescents (34% difference, 95% confidence interval: 20-49). Qualitative and quantitative findings highlighted several misconceptions about the safety, effectiveness, and necessity of COVID-19 vaccines and adolescents' desire for trusted sources of information to address their concerns. Vaccine passports likely increased uptake, yet adolescents were strongly resistant to the policy, and for some, it may have fueled distrust of government and scientific institutions. DISCUSSION: Strategies that increase the trustworthiness of institutions and foster genuine partnership with underserved youth may improve vaccine confidence and help ensure an effective, proequity recovery from COVID-19.

Co-designing a Sexual Health App With Immigrant Adolescents: Protocol for a Qualitative Community-Based Participatory Action Research Study.

BACKGROUND: Canada is one of the world's most ethnically diverse countries, with over 7 million individuals out of a population of 38 million being born in a foreign country. Immigrant adolescents (aged 10 to 19 years) make up a substantial proportion of newcomers to Canada. Religious and cultural practices can influence adolescents' sexual attitudes and behaviors, as well as the uptake of sexual and reproductive health (SRH) services among this population. Adolescence is a time to establish lifelong healthy behaviors. Research indicates an alarming gap in adolescents' SRH knowledge, yet there is limited research on the SRH needs of immigrant adolescents in Canada. OBJECTIVE: The purpose of this study is to actively engage with immigrant adolescents to develop, implement, and evaluate a mobile health (mHealth) intervention (ie, mobile app). The interactive mobile app will aim to deliver accurate and evidence-based SRH information to adolescents. METHODS: We will use community-based participatory action research to guide our study. This research project will be conducted in 4 stages based on user-centered co-design principles. In Stage 1 (Empathize), we will recruit and convene 3 adolescent advisory groups in Edmonton, Toronto, and Vancouver. Members will be engaged as coresearchers and receive training in qualitative and quantitative methodologies, sexual health, and the social determinants of health. In Stage 2 (Define and Ideate), we will explore SRH information and service needs through focus group discussions with immigrant adolescents. In Stage 3 (Prototype), we will collaborate with mobile developers to build and iteratively design the app with support from the adolescent advisory groups. Finally, in Stage 4 (Test), we will return to focus group settings to share the app prototype, gather feedback on usability, and refine and release the app. RESULTS: Recruitment and data collection will be completed by February 2023, and mobile app development will begin in March 2023. The mHealth app will be our core output and is expected to be released in the spring of 2024. CONCLUSIONS: Our study will advance the limited knowledge base on SRH and the information needs of immigrant adolescents in Canada as well as the science underpinning participatory action research methods with immigrant adolescents. This study will address gaps by exploring SRH priorities, health information needs, and innovative strategies to improve the SRH of immigrant adolescents. Engaging adolescents throughout the study will increase their involvement in SRH care decision-making, expand efficiencies in SRH care utilization, and ultimately improve adolescents' SRH outcomes. The app we develop will be transferable to all adolescent groups, is scalable in international contexts, and simultaneously leverages significant economies of scale. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/45389.

Contraception use among female youth with disabilities: Secondary analysis of a Canadian cross-sectional survey.

BACKGROUND: Non-use of contraception among sexually active youth is an important contributor to unintended pregnancy, but contraception use among disabled youth is poorly understood. OBJECTIVE: To compare contraception use in female youth with and without disabilities. METHODS: We used data from the 2013-2014 Canadian Community Health Survey on sexually active 15 to 24-year-old females with (n = 831) and without (n = 2,700) a self-reported functional or activity limitation, who reported that it was important to them to avoid getting pregnant. We used log binomial regression to derive adjusted prevalence ratios (aPR) for use of any vs. no contraception, and for oral contraception, injectable contraception, condoms, other contraception methods, and dual methods separately, comparing youth with and without disabilities. Adjusted analyses controlled for age, school enrollment, household income, marital status, race/ethnicity, immigrant status, and health region. RESULTS: There were no differences in the use of any contraception (85.4% vs. 84.2%; aPR 1.03, 95% CI 0.998-1.06), oral contraception (aPR 0.98, 95% CI 0.92-1.05), condoms (aPR 1.00, 95% CI 0.92-1.09), or dual methods (aPR 1.02, 95% CI 0.91-1.15), comparing youth with and without disabilities. Those with disabilities were more likely to use injectable contraception (aPR 2.31, 95% CI 1.59-3.38) and other contraception methods (aPR 1.54, 95% CI 1.25-1.90). CONCLUSION: Youth at risk of unintended pregnancy had similar overall use of contraception, regardless of disability status. Future studies should examine the reasons for higher uptake of injectable contraception in youth with disabilities, with possible implications for health care provider education on access to youth-controlled methods for this group.

Using human-centred design to tackle COVID-19 vaccine hesitancy for children and youth: a protocol for a mixed-methods study in Montreal, Canada.

INTRODUCTION: To successfully combat COVID-19 vaccine hesitancy and increase uptake, research has demonstrated that interventions are most effective when tailored to meet local needs through active engagement and co-development with communities. This mixed-methods project uses a human-centred design (HCD) approach to understand local perspectives of COVID-19 vaccine hesitancy and develop strategies to enhance vaccine confidence for children and adolescents. METHODS AND ANALYSIS: Project ECHO (Étude Communautaire sur l'Hésitation vaccinale contre la COVID-19) combines population-based surveys of parents and adolescents with community-based participatory action research to design and pilot strategies to enhance COVID-19 vaccine confidence in two underserved and ethnoculturally diverse neighbourhoods of Montreal, Canada. Two surveys conducted 6 months apart through primary and secondary schools are used to monitor vaccine acceptance and its social determinants among children and youth. Analyses of survey data include descriptive and inferential statistical approaches. Community-led design teams of parents and youth from the two participating neighbourhoods, supported by academic researchers, design thinking experts and community partners, use an HCD approach to: (1) gather data to understand COVID-19 vaccine decision-making among parents and youth in their community and frame a design challenge (inspiration phase); (2) develop an intervention to address the design challenge (ideation phase) and (3) pilot the intervention (implementation phase). Strategies to evaluate the community-led interventions will be co-developed during the implementation phase. ETHICS AND DISSEMINATION: This study has been approved by the research ethics boards of the Sainte-Justine University Hospital Centre and the University of Montreal. Community design teams will be involved in the dissemination of findings and the design of knowledge translation initiatives that foster dialogue related to COVID-19 vaccination for children and adolescents among community, school and public health stakeholders. Findings will be disseminated through peer-reviewed publications, conference presentations, community forums, policy briefs, and social media content.

Evaluation of a youth-led participatory action research to address adolescent sexual and reproductive health and rights issues in Senegal.

Participatory approaches are increasingly popular in public health, but remain little used to address adolescent health issues. However, adolescent participation in research has enormous potential for identifying solutions to health issues that concern them. In Senegal, a youth-led participatory action research (YPAR) project was implemented in four communities where teams of adolescents were trained to conduct a research project and identify solutions to address adolescent sexual and reproductive health and rights (ASRHR) issues. This article presents the results of the project evaluation, which aimed to explore the potential of YPAR to address ASRHR issues and inform future YPAR projects. Observations and interviews were carried out during results dissemination meetings in each of the communities. The evaluation of the project demonstrated the potential of YPAR to identify relevant solutions, while promoting positive and meaningful adolescent participation. Despite some difficulties, such as community resistance, the youth researchers were able to successfully complete their research project, while developing their confidence and self-esteem. The adolescents were convinced that they could act as agents of positive social change. This project has shown that it is possible and relevant to involve adolescents in research projects, and that this approach has significant potential in global health.

Cash transfer programs and child health and family economic outcomes: a systematic review.

OBJECTIVES: Family income is an important determinant of child and parental health. In Canada, cash transfer programs to families with children have existed since 1945. This systematic review aimed to examine the association between cash transfer programs to families with children and health outcomes in Canadian children (ages 0 to 18) as well as family economic outcomes. METHODS: We reviewed academic and grey literature published up to November 2021. Additional studies were identified through reference review. We included any study that examined children 0-18 years old and/or their parents, took place in Canada and reported Canada-specific data, and reported child, youth and/or parental health outcomes, as well as family economic outcomes. Risk of bias was assessed by two reviewers using a modified Newcastle-Ottawa Scale. SYNTHESIS: Our search yielded 23 studies meeting the inclusion criteria out of 7052 identified. Eight studies in total measured child health outcomes, including birth outcomes, child overall health, and developmental and behavioural outcomes, and four directly addressed parental health, including mental health, injuries, and obesity. Most studies reported generally positive associations, though some findings were specific to certain subgroups. Some studies also examined fertility and labour force participation outcomes, which described varying effects. CONCLUSION: Cash transfer programs to families with children in Canada are associated with better child and parental health outcomes. Additional research is needed to evaluate the mechanisms of effects, and to identify which types and levels of government transfers are most effective, and target populations, to optimize the positive effects of these benefits.

RéSUMé: OBJECTIFS: Le revenu familial est un important déterminant de la santé infantile et parentale. Au Canada, des programmes de transferts monétaires aux familles avec enfants existent depuis 1945. Notre revue systématique visait à examiner l'association entre les programmes de transferts monétaires aux familles avec enfants et les résultats cliniques chez les enfants canadiens (0 à 18 ans), ainsi que les résultats économiques familiaux. MéTHODE: Nous avons passé en revue la littérature spécialisée et la littérature grise publiées jusqu'en novembre 2021. D'autres études ont été répertoriées par une revue des références. Nous avons inclus toute étude portant sur les enfants de 0 à 18 ans et/ou leurs parents, menée au Canada, rapportant des données propres au Canada et rapportant les résultats cliniques d'enfants, de jeunes et/ou de parents, ainsi que les résultats économiques de familles. Le risque de biais a été évalué par deux évaluateurs à l'aide d'une échelle de Newcastle-Ottawa modifiée. SYNTHèSE: Sur les 7 052 études repérées dans notre recherche, 23 répondaient aux critères d'inclusion. En tout, huit études mesuraient les résultats cliniques d'enfants, dont les issues de la grossesse, la santé globale des enfants et les résultats développementaux et comportementaux, et quatre études portaient directement sur la santé parentale, dont la santé mentale, les blessures et l'obésité. La plupart des études faisaient généralement état d'associations positives, mais certaines constatations étaient spécifiques à certains sous-groupes. Quelques études portaient aussi sur la fécondité et la participation à la population active et décrivaient une diversité d'effets. CONCLUSION: Les programmes de transferts monétaires aux familles avec enfants au Canada sont associés à de meilleurs résultats cliniques infantiles et parentaux. Il faudrait pousser la recherche pour évaluer les mécanismes des effets constatés et pour déterminer quels sont les types et les niveaux de transferts gouvernementaux qui sont les plus efficaces, ainsi que les populations cibles, pour optimiser les effets positifs de ces prestations.

Medical neglect in Ontario: Implications for health care provision.

OBJECTIVES: This study explores child welfare investigations for medical neglect in Ontario, Canada, focusing on household, family and child characteristics of such investigations and factors associated with substantiated victimization. METHODS: This analysis used data from the Ontario Incidence Study of Reported Child Abuse and Neglect 2018. Bivariate analyses compared medical neglect with other neglect investigations to create a profile of medical neglect investigations in Ontario, and a binary logistic regression determined which case characteristics were associated with substantiation of medical neglect. RESULTS: Compared with other neglect investigations, medical neglect investigations were more likely to involve children less than 1 year old and caregivers under 21 years old, households that had run out of money in the past 6 months for basic necessities, primary caregivers with few social supports, mental health issues or drug/solvent abuse concerns, and children with at least one functioning concern. Medical neglect investigations in which the primary caregiver had few social supports were almost four times more likely to be substantiated (OR=3.698, P<0.05). CONCLUSIONS: While the public's perception of medical neglect tends to focus on parental refusal of treatment due to philosophical/religious beliefs, this Ontario sample indicates that medical neglect is often driven by financial constraints and a lack of social support. Implications for health care providers within a universal health care system are discussed.

Adolescents' experiences with group antenatal care: Insights from a mixed-methods study in Senegal.

OBJECTIVES: Group antenatal care (G-ANC) is an innovative model in which antenatal care is delivered to a group of 8-12 women of similar gestational age. Evidence from high-income countries suggests G-ANC is particularly effective for women from marginalised populations, including adolescents. The objective of this study was to examine the experiences of Senegalese adolescents engaged in group antenatal care. METHODS: This convergent parallel mixed-methods study is derived from a larger effectiveness-implementation hybrid pilot study conducted in Kaolack district, Senegal. Quantitative data for adolescent participants were collected through baseline and postnatal surveys and descriptively analysed. One-on-one interviews and focus-group discussions were conducted with adolescent participants, and qualitative data were analysed using qualitative descriptive analysis. RESULTS: Forty-five adolescents aged 15-19 participated in G-ANC, with a median age of 18 years. The majority (93.3%) were married, and 64.4% were nulliparous. Findings indicated similar levels of G-ANC participation for adolescent and adult women. The majority (93.1%) of participants who had previously attended individual ANC indicated they would prefer G-ANC to individual care for a future pregnancy. Qualitative findings indicated key facets of consideration relevant to G-ANC for adolescents include social connectedness, the influence of social norms and the opportunity for engagement in healthcare. CONCLUSIONS: This study suggests that G-ANC has the potential to be an adolescent-responsive and culturally appropriate method of delivering antenatal care in Senegal.

Characteristics of child welfare investigations reported by healthcare professionals in Ontario: secondary analysis of a regional database.

Objectives: This study examines the characteristics and outcomes of child welfare investigations reported by hospital-based and community-based healthcare professionals. Methods: A sample of 7590 child maltreatment-related investigations from the Ontario Incidence Study of Reported Child Abuse and Neglect-2018, a cross-sectional study, was analysed. Bivariate analyses compared characteristics of hospital and community healthcare-reported investigations. Chi-square automatic interaction detector analyses were used to predict the most influential factors in the decision to provide a family with services following a child welfare investigation from each referral source. Results: Community healthcare-reported investigations were more likely to have a primary concern of physical abuse while hospital-reported investigations were more likely to be focused on assessing risk of future maltreatment. Hospital-reported investigations were more likely to involve noted primary caregiver (eg, mental health issues, alcohol/drug abuse, victim of intimate partner violence (IPV)) and household risk factors. The most significant predictor of service provision following an investigation was having a caregiver who was identified as a victim of IPV in hospital-reported investigations (χ2=30.237, df=1, adj. p<0.001) and having a caregiver for whom few social supports was noted in community healthcare-reported investigations (χ2=18.892, df=1, adj. p<0.001). Conclusion: Healthcare professionals likely interact with children who are at high risk for maltreatment. This study's findings highlight the important role that healthcare professionals play in child maltreatment identification, which may differ across hospital-based and community-based settings and has implications for future collaborations between the healthcare and child welfare systems.

"No, You Need to Explain What You Are Doing": Obstetric Care Experiences and Preferences of Adolescent Mothers With a History of Childhood Trauma.

STUDY OBJECTIVE: To understand the pregnancy and childbirth experiences and preferences of adolescent mothers with a history of childhood trauma in order to develop trauma-informed care practice recommendations for this unique group. DESIGN: Mixed methods convergent parallel design involving completion of the Adverse Childhood Experiences (ACE) questionnaire, a survey of care experiences and preferences during pregnancy and delivery, and a one-on-one interview. SETTING: hHospital-based medical home program for pregnant and parenting adolescents. PARTICIPANTS: Adolescent and young adult mothers aged 12-22 years, receiving care between June 2018 and June 2019. RESULTS: A total of 29 adolescent mothers completed the questionnaire, out of a potential 38 in the program (76.3% participation). Five went on to complete an interview. The average age was 17.9 years (standard deviation 1.8 years). The mean ACE score was 5.1 out of 10, indicating childhood exposure to an average of 5 different types of potential trauma. A total of 19 participants (65.5%) reported being triggered during pregnancy or postpartum. Trauma memories were elicited during vaginal examinations in the clinic (27.6%) and in the hospital (27.6%), abdominal examinations (13.8%), measurement of vital signs (17.2%), and labor (17.2%). Ten participants (34.5%) felt that the providers delivering their baby knew how to help them cope with trauma memories. Themes that emerged included the following: acknowledgment of trauma by provider, avoiding re-telling of story, building a relationship with provider, choice and control in care, and providing coping strategies. CONCLUSION: A majority of adolescent mothers in our sample experienced trauma memories during pregnancy and postpartum medical interactions. Priorities for trauma-informed care in this population are described.

The relationship between pubertal timing and under-nutrition in rural Pakistan.

INTRODUCTION: Sexual development in females and males are routinely measured according to the Tanner Stages. Sparse data exist on the timing of pubertal milestones in Pakistan. To fill this gap, the age of attainment of pubertal milestones and their relationship with nutritional status was explored among children and adolescents living in the rural district of Matiari, Pakistan. METHODS: Anthropometry, nutrition biomarkers and Tanner Stage were assessed among girls aged 9.0-14.9 years (n = 723) and boys aged 10.0-15.9 years (n = 662) who were free from known disease in the rural District of Matiari, Pakistan. Median age was calculated for all Tanner Stages and menarche. Multivariable linear regressions were undertaken to determine covariates associated with the timing (age) of pubertal milestones. RESULTS: Among participants living in this rural community, the median age of puberty onset for girls was 11.9 years (95%CI:10.9; 12.5) and boys was 12.3 years (95%CI:11.5; 12.9). Age at first menarche was 12.9 years (95%CI:12.1; 13.3). Undernutrition was widespread among adolescents in this community. Thirty-seven percent of females and 27.0% of males were stunted while 20.5% of females and 31.3% of males were thin. Only 8% (n = 58) of females and 12% (n = 78) of males were free from any nutrient deficiency with most adolescents having two or three nutrient deficiencies. CONCLUSIONS: Undernutrition (stunting or thinness) was associated with relatively older ages for early puberty stages but not puberty completion. This may decrease the duration of the pubertal growth spurt and curtail potential catch-up growth that may occur during puberty. Efforts to decrease nutrient deficiencies, stunting and thinness beyond childhood should be made in rural Pakistan.