Prevalence and clinical, social, and health care predictors of miscarriage.

BACKGROUND: Pregnancy loss is common and several factors (e.g. chromosomal anomalies, parental age) are known to increase the risk of occurrence. However, much existing research focuses on recurrent loss; comparatively little is known about the predictors of a first miscarriage. Our objective was to estimate the population-level prevalence of miscarriages and to assess the contributions of clinical, social, and health care use factors as predictors of the first detected occurrence of these losses. METHODS: In this population-based cohort study, we used linked administrative health data to estimate annual rates of miscarriage in the Manitoba population from 2003 to 2014, as a share of identified pregnancies. We compared the unadjusted associations between clinical, social, and health care use factors and first detected miscarriage compared with a live birth. We estimated multivariable generalized linear models to assess whether risk factors were associated with first detected miscarriage controlling for other predictors. RESULTS: We estimated an average annual miscarriage rate of 11.3%. In our final sample (n = 79,978 women), the fully-adjusted model indicated that use of infertility drugs was associated with a 4 percentage point higher risk of miscarriage (95% CI 0.02, 0.06) and a past suicide attempt with a 3 percentage point higher risk (95% CI -0.002, 0.07). Women with high morbidity were twice as likely to experience a miscarriage compared to women with low morbidity (RD = 0.12, 95% CI 0.09, 0.15). Women on income assistance had a 3 percentage point lower risk (95% CI -0.04, -0.02). CONCLUSIONS: We estimate that 1 in 9 pregnant women in Manitoba experience and seek care for a miscarriage. After adjusting for clinical factors, past health care use and morbidity contribute important additional information about the risk of first detected miscarriage. Social factors may also be informative.

The Association of Inadequate and Intensive Prenatal Care With Maternal, Fetal, and Infant Outcomes: A Population-Based Study in Manitoba, Canada.

OBJECTIVE: Little is known about how prenatal care influences health outcomes in Canada. The objective of this study was to examine the association of prenatal care utilization with maternal, fetal, and infant outcomes in Manitoba. METHODS: This retrospective cohort study conducted at the Manitoba Centre for Health Policy investigated all deliveries of singleton births from 2004-2005 to 2008-2009 (N = 67 076). The proportion of women receiving inadequate, intermediate/adequate, and intensive prenatal care was calculated. Multivariable logistic regression was used to examine the association of inadequate and intensive prenatal care with maternal and fetal-infant health outcomes, health care use, and maternal health-related behaviours. RESULTS: The distribution of prenatal care utilization was 11.6% inadequate, 84.4% intermediate/adequate, and 4.0% intensive. After adjusting for sociodemographic factors and maternal health conditions, inadequate prenatal care was associated with increased odds of stillbirth, preterm birth, low birth weight, small for gestational age (SGA), admission to the NICU, postpartum depressive/anxiety disorders, and short interpregnancy interval to next birth. Women with inadequate prenatal care had reduced odds of initiating breastfeeding or having their infant immunized. Intensive prenatal care was associated with reduced odds of stillbirth, preterm birth, and low birth weight and increased odds of postpartum depressive/anxiety disorders, initiation of breastfeeding, and infant immunization. CONCLUSION: Inadequate prenatal care was associated with increased odds of several adverse pregnancy outcomes and lower likelihood of health-related behaviours, whereas intensive prenatal care was associated with reduced odds of some adverse pregnancy outcomes and higher likelihood of health-related behaviours. Ensuring women receive adequate prenatal care may improve pregnancy outcomes.

Inequities in utilization of prenatal care: a population-based study in the Canadian province of Manitoba.

BACKGROUND: Ensuring high quality and equitable maternity services is important to promote positive pregnancy outcomes. Despite a universal health care system, previous research shows neighborhood-level inequities in utilization of prenatal care in Manitoba, Canada. The purpose of this population-based retrospective cohort study was to describe prenatal care utilization among women giving birth in Manitoba, and to determine individual-level factors associated with inadequate prenatal care. METHODS: We studied women giving birth in Manitoba from 2004/05-2008/09 using data from a repository of de-identified administrative databases at the Manitoba Centre for Health Policy. The proportion of women receiving inadequate prenatal care was calculated using a utilization index. Multivariable logistic regressions were used to identify factors associated with inadequate prenatal care for the population, and for a subset with more detailed risk information. RESULTS: Overall, 11.5% of women in Manitoba received inadequate, 51.0% intermediate, 33.3% adequate, and 4.1% intensive prenatal care (N = 68,132). Factors associated with inadequate prenatal care in the population-based model (N = 64,166) included northern or rural residence, young maternal age (at current and first birth), lone parent, parity 4 or more, short inter-pregnancy interval, receiving income assistance, and living in a low-income neighborhood. Medical conditions such as multiple birth, hypertensive disorders, antepartum hemorrhage, diabetes, and prenatal psychological distress were associated with lower odds of inadequate prenatal care. In the subset model (N = 55,048), the previous factors remained significant, with additional factors being maternal education less than high school, social isolation, and prenatal smoking, alcohol, and/or illicit drug use. CONCLUSION: The rate of inadequate prenatal care in Manitoba ranged from 10.5-12.5%, and increased significantly over the study period. Factors associated with inadequate prenatal care included geographic, demographic, socioeconomic, and pregnancy-related factors. Rates of inadequate prenatal care varied across geographic regions, indicating persistent inequities in use of prenatal care. Inadequate prenatal care was associated with several individual indicators of social disadvantage, such as low income, education less than high school, and social isolation. These findings can inform policy makers and program planners about regions and populations most at-risk for inadequate prenatal care and assist with development of initiatives to reduce inequities in utilization of prenatal care.

Socio-economic inequities in children's injury rates: has the gradient changed over time?

INTRODUCTION: Changing socio-economic gradients in adult health over time have been documented, but little research has investigated temporal changes in child health gradients. Childhood hospitalizations for injury have fallen over the last two decades; whether the socio-economic gradient in childhood injury has changed is unknown. METHODS: Population-based hospital discharge data were used to calculate rates of hospitalization for injury from 1986/87 through 2005/06 for all children under 20 years of age in Manitoba (average yearly number of hospitalizations = 326,357). Information on socio-economic status (SES) came from area-level census data and was assigned by residential postal codes. Generalized linear models with generalized estimating equations were employed to describe the relation between SES and injury rates and whether this relation changed over time. All-cause injuries were examined as well as injuries for motor vehicle collisions (MVCs), other vehicle injuries, self-inflicted injuries, assault, poisoning, injuries caused by machinery, sports injuries and falls. RESULTS: Injury hospitalizations for children decreased steadily over the study period, from 1.07% to 0.51%. SES significantly predicted injury hospitalizations (p < 0.0001), children with lower SES showing higher rates. A significant SES by year interaction (p < 0.0001) indicated that the SES gradient for injury hospitalizations increased over time. Analysis by type of injury found a significant SES by year interaction for MVCs, self-inflicted injuries and falls; for MVCs and self-inflicted injuries the pattern (increasing SES gradient) was similar to that of hospitalization for all-cause injury. The pattern for falls was inconsistent. CONCLUSION: Despite the overall drop in injury hospitalizations over time, the SES gradient in hospitalized injury rates has increased.

Demographic risk factors for fracture in First Nations people.

BACKGROUND: Recently, First Nations people were shown to be at high fracture risk compared with the general population. However, factors contributing to this risk have not been examined. This analysis focusses on geographic area of residence, income level, and diabetes mellitus as possible explanatory variables since they have been implicated in the fracture rates observed in other populations. METHODS: A retrospective, population-based matched cohort study of fracture rates was performed using the Manitoba administrative health data (1987-1999). The First Nations cohort included all Registered First Nations adults (20 years or older) as indicated in either federal and/or provincial files (n = 32,692). Controls (up to three for each First Nations subject) were matched by year of birth, sex and geographic area of residence. After exclusion of unmatched subjects, analysis was based upon 31,557 First Nations subjects and 79,720 controls. RESULTS: Overall and site-specific fracture rates were significantly higher in the First Nations cohort. Income quintile, geographic area of residence, and diabetes were fracture determinants but the excess fracture risk of First Nations ethnicity persisted even after adjustment for these factors. CONCLUSION: First Nations people are at high risk for fracture but the causal factors contributing to this are unclear. Further research is needed to evaluate the importance of other potential explanatory variables.