Association of Human Milk Fatty Acid Composition with Maternal Cardiometabolic Diseases: An Exploratory Prospective Cohort Study.

Background: Human milk fatty acids derive from maternal diet, body stores, and mammary synthesis and may reflect women's underlying cardiometabolic health. We explored whether human milk fatty acid composition was associated with maternal cardiometabolic disease (CMD) during pregnancy and up to 5 years postpartum. Materials and Methods: We analyzed data from the prospective CHILD Cohort Study on 1,018 women with no preexisting CMD who provided breast milk samples at 3-4 months postpartum. Milk fatty acid composition was measured using gas-liquid chromatography. Maternal CMD (diabetes or hypertension) was classified using questionnaires and birth records as no CMD (reference outcome group; 81.1%), perinatal CMD (developed and resolved during the perinatal period; 14.9%), persistent CMD (developed during, and persisted beyond, the perinatal period; 2.9%), and incident CMD (developed after the perinatal period; 1.1%). Multinomial logistic regression was used to model associations between milk fatty acid composition (individual, summary, ratios, and patterns identified using principal component analysis) and maternal CMD, adjusting for pre-pregnancy anthropometry and race/ethnicity. Results: Medium-chain saturated fatty acids (MC-SFA), lauric (C12:0; odds ratio [OR] = 0.73, 95% confidence interval [CI] = 0.60-0.89) and myristic acid (C14:0; OR = 0.80, 95% CI = 0.66-0.97), and the high MC-SFA principal component pattern (OR = 0.86, 95% CI = 0.76-0.96) were inversely associated with perinatal CMD. Long-chain polyunsaturated fatty acids adrenic acid (C22:4n-6) was positively associated with perinatal (OR = 1.21, 95% CI = 1.01-1.44) and persistent CMD (OR = 1.56, 95% CI = 1.08-2.25). The arachidonic (C20:4n-6)-to-docosahexaenoic acid (C22:6n-3) ratio was inversely associated with incident CMD (OR = 0.52, 95% CI = 0.28-0.96). Conclusions: These exploratory findings highlight a potential novel utility of breast milk for understanding women's cardiometabolic health.

Maternal disability and initiation and duration of breastfeeding: analysis of a Canadian cross-sectional survey.

BACKGROUND: The World Health Organization recommends breastfeeding as the best method for infant feeding. Known risk factors for breastfeeding non-initiation and early cessation of breastfeeding are diverse and include low breastfeeding self-efficacy, poverty, smoking, obesity, and chronic illness. Although women with disabilities experience elevated rates of these risk factors, few studies have examined their breastfeeding outcomes. Our objective was to examine breastfeeding non-initiation and early cessation of breastfeeding in women with and without disabilities. METHODS: We used data from the 2017-2018 Canadian Community Health Survey. Included were n = 4,817 women aged 15-55 years who had a birth in the last five years, of whom 26.6% had a disability, ascertained using the Washington Group Short Set on Functioning. Prevalence ratios (aPR) of breastfeeding non-initiation, and of early cessation of any and exclusive breastfeeding before 6 months, were calculated for women with versus without disabilities. We also examined disability by severity (moderate/severe and mild, separately) and number of action domains impacted (≥ 2 and 1, separately). The main multivariable models were adjusted for maternal age, marital status, level of education, annual household income level, and immigrant status. RESULTS: There were no differences between women with and without disabilities in breastfeeding non-initiation (9.6% vs. 8.9%; aPR 0.88, 95% CI 0.63, 1.23). Women with disabilities were more likely to have early cessation of any (44.4% vs. 35.7%) and exclusive breastfeeding before 6 months (66.9% vs. 61.3%), with some attenuation in risk after adjustment for sociodemographic factors (aRR 1.15, 95% CI 0.99, 1.33 and aRR 1.07, 95% 0.98, 1.16, respectively). Disparities were larger for women with moderate/severe disabilities and disabilities in ≥ 2 domains, with differences attenuated by adjustment for socio-demographics. CONCLUSIONS: Women with disabilities, and particularly those with moderate/severe and multiple disabilities, could benefit from tailored, accessible breastfeeding supports that attend to the social determinants of health.

Age and postoperative opioid use in women undergoing pelvic organ prolapse surgery.

INTRODUCTION: Our objective was to explore the relation between patient age and postoperative opioid use up to 24 hours following pelvic organ prolapse (POP) surgery. MATERIAL AND METHODS: We conducted a prospective cohort study following 335 women ranging in age from 26 to 82 years who underwent surgery for multi-compartment POP at a tertiary center in Alberta, Canada. Patient characteristics were measured using baseline questionnaires. Perioperative data were collected from medical chart review during and up to 24 hours following surgery. We used logistic regression to analyze the odds of being opioid-free and linear regression to analyze mean differences in opioid dose, measured as total morphine equivalent daily dose, exploring for a potential non-linear effect of age. Adjusted models controlled for preoperative pain, surgical characteristics and patient health factors. RESULTS: Overall, age was positively associated with greater odds of being opioid-free in the first 24 hours after surgery (adjusted odds ratio per increasing year of age = 1.07, 95% confidence interval [CI] 1.04-1.09, n = 332 women). Among opioid users, age was inversely associated with total opioid dose (adjusted mean difference per increasing year of age = 0.71 mg morphine equivalent daily dose, 95% CI -0.99 to -0.44, n = 204 women). There was no evidence of a non-linear relation between age and postoperative opioid use or dose. CONCLUSIONS: In the context of POP surgery, we found that younger women were more likely to use opioids after surgery and to use a higher dose in the first 24 hours when compared with older women. These findings support physicians to consider age when counseling POP patients regarding pain management after surgery, and to direct resources aimed at opioid-free pain control towards younger patients.

Small for gestational age preterm infants and later adiposity and height: A systematic review and meta-analysis.

BACKGROUND: Overweight and obesity and their consequent morbidities are important worldwide health problems. Some research suggests excess adiposity origins may begin in fetal life, but unknown is whether this applies to infants born preterm. OBJECTIVE: The objective of the study was to assess the association between small for gestational age (SGA) birth and later adiposity and height among those born preterm. DATA SOURCES: MEDLINE, EMBASE and CINAHL until October 2022. STUDY SELECTION AND DATA EXTRACTION: Studies were included if they reported anthropometric (adiposity measures and height) outcomes for participants born preterm with SGA versus non-SGA. Screening, data extraction and risks of bias assessments were conducted in duplicate by two reviewers. SYNTHESIS: We meta-analysed across studies using random-effects models and explored potential heterogeneity sources. RESULTS: Thirty-nine studies met the inclusion criteria. In later life, preterm SGA infants had a lower body mass index (-0.66 kg/m2 , 95% CI -0.79, -0.53; 32 studies, I2 = 16.7, n = 30,346), waist circumference (-1.20 cm, 95% CI -2.17, -0.23; 13 studies, I2 = 19.4, n = 2061), lean mass (-2.62 kg, 95% CI -3.45, 1.80; 7 studies, I2 = 0, n = 205) and height (-3.85 cm, 95% CI -4.73, -2.96; 26 studies, I2 = 52.6, n = 4174) compared with those preterm infants born non-SGA. There were no differences between preterm SGA and preterm non-SGA groups in waist/hip ratio, body fat, body fat per cent, truncal fat per cent, fat mass index or lean mass index, although power was limited for some analyses. Studies were rated at high risk of bias due to potential residual confounding and low risk of bias in other domains. CONCLUSIONS: Compared to their preterm non-SGA peers, preterm infants born SGA have lower BMI, waist circumference, lean body mass and height in later life. No differences in adiposity were observed between SGA preterm infants and non-SGA preterm infants.

Comparison of Emergency Department Use Between Pregnant People With and Without Disabilities in Ontario, Canada.

Importance: Emergency department (ED) use in pregnancy is common and occurs for a variety of reasons, including obstetrical complications, exacerbated underlying conditions, and inadequate outpatient health care access. People with disabilities have elevated rates of certain medical, psychiatric, and obstetrical conditions as well as inadequate access to prenatal care; their risk of ED use in pregnancy is not known, however. Objective: To compare the risk of ED use in pregnancy among people with physical, sensory, and intellectual or developmental disabilities with those without disabilities. Design, Setting, and Participants: Population-based cohort study leveraging linked administrative health data sets in Ontario, Canada, April 2003 to March 2019. Analysis included all recognized pregnancies to people with a preexisting physical, sensory, intellectual or developmental, or 2 or more (multiple) disabilities, and those without a disability. Data were analyzed from May 2022 to January 2023. Exposure: Disability was ascertained using algorithms applied to 2 or more outpatient physician visits or 1 or more ED visits or hospitalizations before conception. Main outcomes and measures: Modified Poisson regression-generated adjusted relative risks (aRR) and 95% CIs for any ED visit in pregnancy, from the estimated conception date up to the end of the pregnancy, adjusted for age, parity, income quintile, rurality, immigrant status, and preexisting chronic conditions, mental illness, and substance use disorders. Results: The cohort included 2 659 895 pregnant people with physical (221 739 participants; mean [SD] age, 29.8 [6.1] years), sensory (71 891 participants; mean [SD] age, 29.1 [6.4] years), intellectual or developmental (3877 participants; mean [SD] age, 26.1 [6.7] years), and multiple disabilities (14 359 participants; mean [SD] age, 29.5 [6.5] years), and pregnant people without a disability (2 348 023 participants; mean [SD] age, 29.4 [5.9] years). The rate of ED visits in pregnancy was 25.4% in people without a disability (596 771 visits). Relative to these individuals, the aRR for ED use was elevated in people with physical (aRR, 1.26; 95% CI, 1.25-1.27), sensory (aRR, 1.15; 95% CI, 1.14-1.17), intellectual or developmental (aRR, 1.33; 95% CI, 1.28-1.38), and multiple disabilities (aRR, 1.43; 95% CI, 1.40-1.46). Conclusions and Relevance: In this population-based study, people with disabilities were at elevated risk of ED use in pregnancy. This finding underscores the need for research on the benefits of proactive strategies to manage preexisting conditions in these individuals, improve their access to outpatient obstetrical and medical care, and prepare them for when ED visits occur.

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.

Association of infertility with type and timing of menopause: a prospective cohort study.

STUDY QUESTION: What is the association between past infertility and the type and timing of menopause in midlife women? SUMMARY ANSWER: Women with a history of infertility were more likely to experience surgical menopause overall and had elevated risk of earlier surgical menopause until age 43 years but experienced no differences in the timing of natural menopause. WHAT IS KNOWN ALREADY: Infertility is experienced by 12-25% of women and is thought to reveal a propensity for poor health outcomes, such as chronic illness, later in life. However, little is known about whether infertility is linked with characteristics of the menopausal transition as women age, despite possible shared underlying pathways involving ovarian function and gynecologic disease. STUDY DESIGN, SIZE, DURATION: Secondary analysis of a prospective cohort study of 13 243 midlife females recruited in Phase 1 of the Alberta's Tomorrow Project (Alberta, Canada) and followed approximately every 4 years (2000-2022). PARTICIPANTS/MATERIALS, SETTING, METHODS: Data were collected through standardized self-report questionnaires. History of infertility, defined as ever trying to become pregnant for more than 1 year without conceiving, was measured at baseline. Menopause characteristics were measured at each study follow-up. Menopause type was defined as premenopause, natural menopause, surgical menopause (bilateral oophorectomy), or indeterminate menopause (premenopausal hysterectomy with ovarian conservation). Timing of natural menopause was defined as the age at 1 full year after the final menstrual period, and timing of surgical and indeterminate menopause was defined as the age at the time of surgery. We used flexible parametric survival analysis for the outcome of menopause timing with age as the underlying time scale and multinomial logistic regression for the outcome of menopause type. Multivariable models controlled for race/ethnicity, education, parity, previous pregnancy loss, and smoking. Sensitivity analyses additionally accounted for birth history, menopausal hormone therapy, body mass index, chronic medical conditions, and age at baseline. MAIN RESULTS AND THE ROLE OF CHANCE: Overall, 18.2% of women reported a history of infertility. Past infertility was associated with earlier timing of surgical menopause exclusively before age 43 years (age 35: adjusted hazard ratio 3.13, 95% CI 1.95-5.02; age 40: adjusted hazard ratio 1.83, 95% CI 1.40-2.40; age 45: adjusted hazard ratio 1.13, 95% CI 0.87-1.46) as well as greater odds of experiencing surgical menopause compared to natural menopause (adjusted odds ratio 1.40, 95% CI 1.18-1.66). Infertility was not associated with the timing of natural or indeterminate menopause. LIMITATIONS, REASONS FOR CAUTION: Information on the underlying cause of infertility and related interventions was not collected, which precluded us from disentangling whether associations differed by infertility cause and treatment. Residual confounding is possible given that some covariates were measured at baseline and may not have temporally preceded infertility. WIDER IMPLICATIONS OF THE FINDINGS: Women with a history of infertility were more likely to experience early surgical menopause and may therefore benefit from preemptive screening and treatment for gynecologic diseases to reduce bilateral oophorectomy, where clinically appropriate, and its associated health risks in midlife. Moreover, the lack of association between infertility and timing of natural menopause adds to the emerging knowledge that diminishing ovarian reserve does not appear to be a primary biological mechanism of infertility nor its downstream implications for women's health. STUDY FUNDING/COMPETING INTEREST(S): Alberta's Tomorrow Project is only possible due to the commitment of its research participants, its staff and its funders: Alberta Health, Alberta Cancer Foundation, Canadian Partnership Against Cancer and Health Canada, and substantial in-kind funding from Alberta Health Services. The views expressed herein represent the views of the author(s) and not of Alberta's Tomorrow Project or any of its funders. This secondary analysis is funded by Project Grant Priority Funding in Women's Health Research from the Canadian Institutes of Health Research (Grant no. 491439). N.V.S. is supported by a Banting Postdoctoral Fellowship from the Canadian Institutes of Health Research. H.K.B. is supported by the Canada Research Chairs Program. E.A.B. is supported by an Early Career Investigator Award in Maternal, Reproductive, Child and Youth Health from the Canadian Institutes of Health Research. A.K.S. has received honoraria from Pfizer, Lupin, Bio-Syent, and Eisai and has received grant funding from Pfizer. N.V.S., H.K.B., and E.A.B. have no conflicts of interest to report. TRIAL REGISTRATION NUMBER: N/A.

Association of illness perceptions and exclusive breastfeeding intentions among pregnant women with chronic conditions: A community-based pregnancy cohort study.

OBJECTIVE: We examined whether changes in illness perceptions from preconception to pregnancy were associated with intentions to exclusively breastfeed to 6 months postpartum among women with chronic physical health conditions. METHODS: We analyzed self-reported cross-sectional questionnaire data collected in the third trimester from 361 women with chronic conditions enrolled in a community-based cohort study (Alberta, Canada). For individual and total illness perceptions, measured with the Brief Illness Perception Questionnaire, women were classified using change scores (preconception minus pregnancy) into one of the following groups: "worsening," "improving," or "stable" in pregnancy. Intention to exclusively breastfeed was defined as plans to provide only breast milk for the recommended first 6 months after birth. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using multivariable logistic regression modelling, with the "stable" group as the reference and controlling for demographic factors, chronic condition duration and medication, prenatal class attendance, and social support. RESULTS: Overall, 61.8% of women planned to exclusively breastfeed to 6 months. Worsened total illness perceptions (adjusted OR 0.50, 95% CI 0.30-0.82) as well as perceptions of worsened identity (i.e., degree of symptoms; adjusted OR 0.49, 95% CI 0.28-0.85) or consequences (i.e., impact on functioning; adjusted OR 0.60, 95% CI 0.34-1.06) were associated with lower odds of intending to exclusively breastfeed to 6 months. CONCLUSIONS: Women who perceive their illness experience to worsen during pregnancy are less likely to plan to exclusively breastfeed to 6 months in accordance with public health recommendations.

Factors affecting women's decision between uterine-preserving versus hysterectomy-based surgery for pelvic organ prolapse.

BACKGROUND: Given the prevalence of women seeking surgical treatment for pelvic organ prolapse (POP), there is a need to understand women's decision-making regarding uterine-preserving versus hysterectomy-based surgeries. Historically, hysterectomy-based surgeries have been the preferred treatment for pelvic organ prolapse; however, contemporary evidence supports uterine-preserving surgeries as equivalent. At present, the lack of information available to the general public and limited options presented at surgical consultation for pelvic organ prolapse may hinder women's autonomy as they navigate surgical treatment. OBJECTIVES: To examine the factors affecting women's decision-making processes regarding uterine-preserving or hysterectomy-based surgery for pelvic organ prolapse. DESIGN: This is a qualitative study. METHODS: We conducted semi-structured, qualitative interviews with women seeking surgery for pelvic organ prolapse to explore the factors affecting women's decision-making between hysterectomy-based and uterine-preserving surgeries. RESULTS: Women (n = 26) used clinical and personal factors to determine which surgery was best. Women noted that the lack of evidence (clinical and/or anecdotal) available to them hindered their decision-making, causing them to rely more on their own interpretations of the evidence, what they perceived to be "normal," and what their surgeon recommended. Even with standardized discussion regarding the existing clinical equipoise between surgeries at the clinical consultation, some women still had misperceptions that hysterectomy-based surgery would convey the lowest risk of prolapse recurrence and be best for severe prolapse. CONCLUSION: There is a need for more transparency in discussions about prolapse and the factors affecting women's decision-making for surgical repair of pelvic organ prolapse. Clinicians should be prepared to offer the option of hysterectomy-based or uterine-preserving surgeries and to clearly explain the clinical equipoise between these procedures.

Exclusion of pregnant and lactating persons from breast cancer clinical trials: a review of active trials registered on ClinicalTrials.gov.

INTRODUCTION: Treatment of pregnancy-associated breast cancer is complex, as providers try to balance risks to the pregnant person and the developing fetus. Given increased case fatality and increasing incidence, there is a pressing need understand the efficacy and safety of different treatment regimens in this population; however, pregnant and lactating people have traditionally been excluded from participating in randomized controlled trials (RCTs). Given recent efforts to expand the inclusion criteria for oncology RCTs, this study aimed to review the inclusion/exclusion criteria of current breast cancer RCTs to assess what proportion of trials permitted enrollment of pregnant and lactating persons. MATERIAL AND METHODS: We conducted a comprehensive search of ClinicalTrials.gov in January 2022 to identify interventional studies of breast cancer in adults that were actively recruiting. The primary outcomes were the exclusion of pregnant and lactating people. RESULTS: The search identified 1706 studies, of which 1451 met eligibility criteria. Overall, 69.4% and 54.8% of studies excluded pregnant and lactating people, respectively. The exclusion of pregnant and lactating persons differed by study characteristics but extended across all trial designs, locations, phases and interventions. Exclusion of pregnant and lactating persons was most common in trials where the intervention was biological (86.3%), drug (83.5%) or radiation (81.5%). CONCLUSIONS: The exclusion of pregnant and lactating people from clinical trials contributes to evidence gaps in how to treat this population. A paradigm shift is needed that focuses on how research can be used to protect pregnant people from future harms, instead of protecting pregnant people from research-related risks.

Breastfeeding difficulties in the first 6 weeks postpartum among mothers with chronic conditions: a latent class analysis.

BACKGROUND: Breastfeeding difficulties frequently exacerbate one another and are common reasons for curtailed breastfeeding. Women with chronic conditions are at high risk of early breastfeeding cessation, yet limited evidence exists on the breastfeeding difficulties that co-occur in these mothers. The objective of this study was to explore clusters of breastfeeding difficulties experienced up to 6 weeks postpartum among mothers with chronic conditions and to examine associations between chronic condition types and breastfeeding difficulty clusters. METHODS: We analyzed 348 mothers with chronic conditions enrolled in a prospective, community-based pregnancy cohort study from Alberta, Canada. Data were collected through self-report questionnaires. We used latent class analysis to identify clusters of early breastfeeding difficulties and multinomial logistic regression to examine whether types of chronic conditions were associated with these clusters, adjusting for maternal and obstetric factors. RESULTS: We identified three clusters of breastfeeding difficulties. The "physiologically expected" cluster (51.1% of women) was characterized by leaking breasts and engorgement (reference outcome group); the "low milk production" cluster (15.4%) was discerned by low milk supply and infant weight concerns; and the "ineffective latch" cluster (33.5%) involved latch problems, sore nipples, and difficulty with positioning. Endocrine (adjusted relative risk ratio [RRR] 2.34, 95% CI 1.10-5.00), cardiovascular (adjusted RRR 2.75, 95% CI 1.01-7.81), and gastrointestinal (adjusted RRR 2.51, 95% CI 1.11-5.69) conditions were associated with the low milk production cluster, and gastrointestinal (adjusted RRR 2.44, 95% CI 1.25-4.77) conditions were additionally associated with the ineffective latch cluster. CONCLUSION: Half of women with chronic conditions experienced clusters of breastfeeding difficulties corresponding either to low milk production or to ineffective latch in the first 6 weeks postpartum. Associations with chronic condition types suggest that connections between lactation physiology and disease pathophysiology should be considered when providing breastfeeding support.

Small for date preterm infants and risk of higher blood pressure in later life: A systematic review and meta-analysis.

BACKGROUND: Historical reports suggest that infants born small for gestational age (SGA) are at increased risk for high blood pressure (BP) at older ages after adjustment for later age body size. Such adjustment may be inappropriate since adiposity is a known cause of cardiovascular and metabolic disease. OBJECTIVES: To assess the association between SGA births and later BP among preterm births, considering potential background confounders and over-adjustment for later body size. METHODS: A database search of studies up to October 2022 included MEDLINE, EMBASE and CINAHL. Studies were included if they reported BP (systolic [SBP] or diastolic [DBP]) (outcomes) for participants born preterm with SGA (exposure) or non-SGA births. All screening, extraction steps, and risk of bias (using the Risk of Bias In Non-randomised Studies of Interventions [ROBINS-I] tool) were conducted in duplicate by two reviewers. Data were pooled in meta-analysis using random-effects models. We explored potential sources of heterogeneity. RESULTS: We found no meaningful difference in later BP between preterm infants with and without SGA status at birth. Meta-analysis of 25 studies showed that preterm SGA, compared to preterm non-SGA, was not associated with higher BP at age 2 and older with mean differences for SBP 0.01 mmHg (95% CI -0.10, 0.12, I2  = 59.8%, n = 20,462) and DBP 0.01 mm Hg (95% CI -0.10, 0.12), 22 studies, (I2  = 53.0%, n = 20,182). Adjustment for current weight did not alter the results, which could be due to the lack of differences in later weight status in most of the included studies. The included studies were rated to be at risk of bias due to potential residual confounding, with a low risk of bias in other domains. CONCLUSIONS: Evidence indicates that preterm infants born SGA are not at increased risk of developing higher BP as children or as adults as compared to non-SGA preterm infants.

Association of postpartum medication practices with early breastfeeding cessation among mothers with chronic conditions: A prospective cohort study.

INTRODUCTION: Use of medications is a common concern for breastfeeding women, particularly when they are strongly needed or unavoidable to manage maternal chronic conditions. Yet the influence of medication usage patterns on breastfeeding duration in mothers with chronic conditions is unclear. The objective of this study was to examine whether postpartum medication practices were associated with shorter breastfeeding duration or earlier than planned breastfeeding cessation among mothers with chronic conditions. MATERIAL AND METHODS: We analyzed 346 mothers with chronic conditions enrolled in a prospective, community-based pregnancy cohort study (Alberta, Canada) who initiated breastfeeding after birth. Data were collected through self-report questionnaires spanning late pregnancy to 6 months postpartum. Based on reported use of preexisting medications while breastfeeding, women were classified as continuing medications (reference group), discontinuing one or more medications, or those who did not use preexisting medications. Cox proportional hazards regression was used to analyze the association of medication practices and overall breastfeeding duration in weeks. Logistic regression was used to analyze the association of medication practices and earlier than planned breastfeeding cessation. Multivariable models adjusted for demographic and health-related factors. RESULTS: Overall, 30.6% of women with chronic conditions stopped breastfeeding in the first 6 months, almost all of whom did so earlier than planned. In multivariable models, medication discontinuation was significantly associated with shorter breastfeeding duration (adjusted hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.03-2.70) and earlier than planned breastfeeding cessation (adjusted odds ratio [OR] 1.85, 95% CI 1.01-3.42), whereas medication non-use was not associated with differences in breastfeeding outcomes. CONCLUSIONS: Women with chronic conditions who discontinued preexisting medications while breastfeeding had significantly shorter breastfeeding duration and were less likely to meet their breastfeeding goals in the first 6 months postpartum compared to women who continued preexisting medications.

Association of Caesarean delivery and breastfeeding difficulties during the delivery hospitalization: a community-based cohort of women and full-term infants in Alberta, Canada.

OBJECTIVE: Breastfeeding difficulties are the most common reason for breastfeeding cessation, particularly in the early postpartum. Caesarean delivery is associated with earlier breastfeeding cessation than is the case with vaginal delivery, but differences in breastfeeding difficulties by mode of delivery have not been thoroughly examined. Our objective was to explore the association between Caesarean delivery and types of breastfeeding difficulties. METHODS: We conducted a secondary analysis of data from a prospective cohort study of mothers who delivered full-term, singleton infants in Calgary, Alberta, Canada (N = 418). Women completed self-report questionnaires during the delivery hospitalization. Mode of delivery was defined as vaginal or Caesarean, and further classified as planned or unplanned Caesarean. Breastfeeding difficulties were measured using the Breastfeeding Experiences Scale and operationalized with binary variables for presence of various types of maternal (i.e. physical, supply, social) and infant (i.e. latch, behaviour/health) difficulties that were reported as moderate to unbearable. Multivariable logistic regression was used to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CIs). RESULTS: Overall, 37.1% of women had a Caesarean delivery and 80.9% experienced a breastfeeding difficulty during the delivery hospitalization. Of the difficulties studied, Caesarean delivery was significantly associated with low milk supply (AOR = 1.62, 95% CI = 1.16-2.28) and infant behaviour/health difficulties (AOR = 1.33, 95% CI = 1.01-1.75). The association with low milk supply persisted when examining both planned (AOR = 2.42, 95% CI = 1.19-4.92) and unplanned (AOR = 2.21, 95% CI = 1.16-4.22) Caesarean deliveries. CONCLUSION: Mothers who deliver by Caesarean have higher odds of reporting low milk supply and infant behaviour/health difficulties than women who deliver vaginally.

RéSUMé: OBJECTIF: Les difficultés d'allaitement sont la principale raison de l'arrêt de l'allaitement, surtout au début de la période du postpartum. L'accouchement par césarienne est associé à un arrêt de l'allaitement plus précoce qu'avec l'accouchement par voie vaginale, mais les différences dans les difficultés d'allaitement selon la voie d'accouchement n'ont pas été étudiées à fond. Nous avons voulu explorer les associations entre l'accouchement par césarienne et les types de difficultés d'allaitement. MéTHODE: Nous avons effectué une analyse secondaire des données d'une étude prospective de cohortes de mères ayant accouché à terme d'un bébé unique à Calgary (Alberta) au Canada (N = 418). Les femmes ont rempli des questionnaires d'autoévaluation durant leur hospitalisation après l'accouchement. Pour la voie d'accouchement, les répondantes avaient le choix entre un accouchement par voie vaginale ou par césarienne, puis par césarienne planifiée ou non planifiée. Les difficultés d'allaitement ont été mesurées à l'aide d'une échelle de l'expérience d'allaitement (Breastfeeding Experiences Scale) et opérationnalisées avec des variables binaires pour détecter la présence de divers types de difficultés éprouvées par les mères (c.-à-d. physiques, sociales, de production de lait) et par les nourrissons (c.-à-d. prise du sein, comportement/santé) déclarées par les mères comme étant de modérées à insupportables. Une analyse de régression logistique multivariée a servi à estimer les rapports de cotes ajustés (RCa) et les intervalles de confiance de 95 % (IC). RéSULTATS: Dans l'ensemble, 37,1 % des femmes avaient accouché par césarienne, et 80,9 % avaient éprouvé une difficulté d'allaitement durant leur hospitalisation après l'accouchement. De toutes les difficultés étudiées, l'accouchement par césarienne présentait une corrélation significative avec la faible production de lait (RCa = 1,62, IC de 95 % = 1,16-2,28) et avec les difficultés de comportement/de santé du nourrisson (RCa = 1,33, IC de 95 % = 1,01-1,75). L'association avec la faible production de lait est demeurée lorsque nous avons examiné les accouchements par césarienne planifiés (RCa = 2,42, IC de 95 % = 1,19-4,92) et non planifiés (RCa = 2,21, IC de 95 % = 1,16-4,22). CONCLUSION: Chez les mères ayant accouché par césarienne, la probabilité de déclarer une faible production de lait et des difficultés de comportement/de santé du nourrisson est plus élevée que chez les femmes ayant accouché par voie vaginale.

Impact of lifetime lactation on the risk and duration of frequent vasomotor symptoms: A longitudinal dose-response analysis.

OBJECTIVE: To examine the association between lifetime lactation and risk and duration of frequent vasomotor symptoms (VMS). DESIGN: Prospective cohort. SETTING: USA, 1995-2008. SAMPLE: 2356 parous midlife women in the Study of Women's Health Across the Nation. METHODS: Lifetime lactation was defined as the duration of breastfeeding across all births in months. We used generalised estimating equations to analyse risk of frequent VMS and Cox regression to analyse duration of frequent VMS in years. MAIN OUTCOME MEASURES: Frequent VMS (hot flashes and night sweats) were measured annually for 10 years, defined as occurring ≥6 days in the past 2 weeks. RESULTS: Overall, 57.1% of women reported hot flashes and 43.0% reported night sweats during follow-up. Lifetime lactation was inversely associated with hot flashes plateauing at 12 months of breastfeeding (6 months: adjusted odds ratio [AOR] 0.85, 95% confidence interval (CI) 0.75-0.96; 12 months: AOR 0.78, 95% CI 0.65-0.93) and was inversely associated with night sweats in a downward linear fashion (6 months: AOR 0.93, 95% CI 0.81-1.08; 18 months: AOR 0.82, 95% CI 0.67-1.02; 30 months: AOR 0.73, 95% CI 0.56-0.97). Lifetime lactation was associated with shorter duration of hot flashes and night sweats in a quadratic (bell-shaped) fashion. The association was strongest at 12-18 months of breastfeeding and significant for hot flashes (6 months: adjusted hazard ratio [AHR] 1.35, 95% CI 1.11-1.65; 18 months: AHR 1.54, 95% CI 1.16-2.03; 30 months: AHR 1.18, 95% CI 0.83-1.68). CONCLUSIONS: Longer lifetime lactation is associated with decreased risk and duration of frequent VMS.

Second trimester cytokine profiles associated with gestational diabetes and hypertensive disorders of pregnancy.

Healthy pregnancy requires a coordinated immune response, yet complications can arise, putting both the mother's and child's health at risk. Hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) are pregnancy-related complications that account for most maternal morbidity and mortality. Cytokines are proteins released as part of the immune response to disease or infection and regulate inflammation. Certain pregnancy complications cause localized and systemic inflammation; however, cytokine profiles specific to such complications are not well understood. This study aims to examine associations between pregnancy complications of HDP and GDM and cytokine profiles in the second trimester of pregnancy. Data was obtained from the All Our Families birth cohort in Calgary, Alberta, Canada. The cohort collected questionnaires at the time of participant enrollment and maternal blood samples at 17-23 weeks gestation. Cases of HDP (n = 27) and GDM (n = 31) were matched to controls on BMI, maternal age, and smoking status in the preconception period at a 1:3 ratio. Cytokine levels were measured in blood samples using Luminex xMAP technology using a panel of 42 cytokines. Using R software, a Classification and Regression Tree (CART) analysis was conducted to identify cytokine profiles and levels associated with each complication. Four cytokines were identified in the HDP CART (in descending order of importance): Monocyte Chemoattractant Protein-1 (cut-off: <480pg/mL), Macrophage Inflammatory Protein-1ß (cut-off: ≥26pg/mL), Eotaxin (cut-off: <27/≥27&<36/≥36pg/mL), and Soluble Cluster of Differentiation 40 Ligand (cut-off: <1342pg/mL). Six cytokine levels were identified in the GDM CART: Interleukin-1 Receptor Antagonist (IL-1Ra; cut-off: <25pg/mL), Interleukin-5 (cut-off: ≥0.4pg/mL), Interferon-γ (cut-off: <4.9pg/mL), IL-1Ra (cut-off: ≥111pg/mL), Eotaxin (cut-off: ≥21pg/mL), and Interleukin-18 (cut-off: ≥155pg/mL). By examining the complex inter-relationships between cytokines, findings of cytokine profiles guide further research in identifying biomarkers of pregnancy complications relevant to the design of the future management or prevention of these conditions.

Recurrent pregnancy loss and incident arthritis in midlife: an exploratory longitudinal analysis of the Study of Women's Health Across the Nation.

PURPOSE: To explore the association between recurrent pregnancy loss (RPL) and incident arthritis in midlife women. METHODS: We analyzed the U.S. Study of Women's Health Across the Nation, a multi-ethnic cohort following pre- or peri­menopausal women, using data from baseline up to the tenth annual follow-up visit. Discrete survival analysis was used to estimate adjusted hazard ratios and 95% confidence intervals for risk of incident arthritis at annual intervals in women with versus without RPL. RESULTS: Of the 2159 participants analyzed, 8.5% reported a history of RPL. Cumulative incidence of arthritis was 43.3% in women with RPL and 40.1% in women without RPL, though differences between groups varied over time. Significant associations were observed only at visits three to seven, with the strongest associations at visits four to six. The adjusted hazard ratios (95% confidence intervals) were 1.80 (1.30-2.50) at visit 4 (median age = 50 years), 1.95 (1.38-2.75) at visit 5 (median age = 51 years), and 1.82 (1.28-2.58) at visit 6 (median age = 52 years). CONCLUSIONS: Women with previous RPL may have elevated risk of arthritis specifically when entering their 50s, on average. Additional research is needed to determine whether women with a history of RPL may benefit from early detection of arthritis in midlife.

Association of lifetime lactation and age at natural menopause: a prospective cohort study.

OBJECTIVE: The aim of this study was to examine the association between duration of lifetime lactation and age at natural menopause. METHODS: In this prospective cohort study, we analyzed parous premenopausal women in the multiethnic Study of Women's Health Across the Nation who were followed approximately annually for 10 years (1995-2008). Lifetime lactation was defined as the duration of breastfeeding across all births in months. Age at natural menopause was defined as age in years after 12 consecutive months of amenorrhea after the final menstrual period for no other reported cause. We used Cox proportional hazard models to analyze time to natural menopause with age as the underlying time scale. Multivariable models controlled for education, race/ethnicity, parity, smoking, body mass index, and oral contraceptive use. RESULTS: Among 2,377 women, 52.6% experienced natural menopause during follow-up and reported a valid final menstrual period date. The small, crude association between lifetime lactation up to 24 months and later age at natural menopause attenuated to nonsignificance in adjusted models (6 months: adjusted hazard ratio [AHR], 0.96; 95% confidence interval (CI), 0.87-1.06; 12 months: AHR, 0.95; 95% CI, 0.82-1.11; 18 months: AHR, 0.96; 95% CI, 0.82-1.13; 24 months: AHR, 0.99; 95% CI, 0.84-1.16). CONCLUSIONS: Duration of lifetime lactation was not associated with age at natural menopause after controlling for sociodemographic characteristics.

Development of symptomatic pelvic organ prolapse over 10 years of mid-life follow-up is affected by occupational lifting and/or pushing for parous women.

OBJECTIVE: To document the risk of new-onset symptomatic pelvic organ prolapse (POP) among perimenopausal women and examine whether occupational lifting and/or pushing is a risk factor in the development of POP over a 10-year follow-up window. STUDY DESIGN: Secondary analysis of prospective, longitudinal data from the Study of Women's Health Across the Nation (SWAN) cohort study. MAIN OUTCOME MEASURES: We analyzed women with current employment at the start of SWAN who were followed annually during mid-life. At baseline, women self-reported the frequency of occupational lifting and pushing, which was classified as Never, Infrequent (less than half the time), or Frequent (half the time or more) occupational lifting and/or pushing. Women were asked about new-onset symptomatic POP from the second to tenth annual follow-up. Modified Poisson regression was used to quantify crude and adjusted risk ratios (RRs) and 95 % confidence intervals (CIs) for POP according to load-bearing categories. Parous women were modelled separately, as initial analyses suggested effect modification by parity status. RESULTS: In our sample of 1590 parous women, 8.2 % reported new-onset symptomatic POP over 10 years of follow-up. Multivariable analysis revealed that Infrequent (aRR 1.51, 95 % CI 1.04-2.20) and Frequent (aRR 2.03, 95 % CI 1.29-3.17) occupational lifting and/or pushing were associated with the development of POP. CONCLUSION: Frequent occupational lifting and/or pushing significantly increased parous women's risk of developing POP symptoms. This strengthens existing evidence that occupational exposures can be risk factors for POP. Gender-based education and prevention strategies in the workplace and in primary health care are necessary to reduce the burden of this condition for mid-life women.

"Broken"-How Identities as Women, Mothers and Partners Are Intertwined with the Experience of Living with and Seeking Treatment for Pelvic Organ Prolapse.

Pelvic Organ Prolapse (POP) occurs when one or more pelvic organs descend into or through the vaginal opening, significantly impacting physical and mental health. POP affects the female reproductive tract and, overwhelmingly, people who identify as women. However, little research has examined the impact of gendered expectations on women's treatment-seeking for POP and their decision-making around surgery for POP. To address this gap, we conducted semi-structured interviews with 26 women seeking surgery for POP in Alberta, Canada. Data were analyzed from a gender-based lens, using the Framework Method. Participants reported the need to balance their identities as women, partners, and mothers in their pursuit of treatment and faced many barriers to treatment related to their gendered responsibilities. Findings highlight the gendered experiences of prolapse in the context of healthcare needs and can inform policies and practices which promote more equitable access to prolapse treatment.