Long-term healthcare utilization and costs of babies born after assisted reproductive technologies (ART): a record linkage study with 10-years' follow-up in England.

STUDY QUESTION: Is the long-term health care utilization of children born after ART more costly to the healthcare system in England than children born to mothers with no fertility problems? SUMMARY ANSWER: Children born after ART had significantly more general practitioner (GP) consultations and higher primary care costs up to 10 years after birth, and significantly higher hospital admission costs in the first year after birth, compared to children born to mothers with no fertility problems. WHAT IS KNOWN ALREADY: There is evidence that children born after ART are at an increased risk of adverse birth outcomes and a small increased risk of rare adverse outcomes in childhood. STUDY DESIGN, SIZE, DURATION: We conducted a longitudinal study of 368 088 mother and baby pairs in England using a bespoke linked dataset. Singleton babies born 1997-2018, and their mothers, who were registered at GP practices in England contributing data to the Clinical Practice Research Datalink (CPRD), were identified through the CPRD GOLD mother-baby dataset; this data was augmented with further linkage to the mothers' Human Fertilisation and Embryology Authority (HFEA) Register data. Four groups of babies were identified through the mothers' records: a 'fertile' comparison group, an 'untreated sub-fertile' group, an 'ovulation induction' group, and an ART group. Babies were followed-up from birth to 28 February 2021, unless censored due to loss to follow-up (e.g. leaving GP practice, emigration) or death. PARTICIPANTS/MATERIALS, SETTING, METHODS: The CPRD collects anonymized coded patient electronic health records from a network of GPs in the UK. We estimated primary care costs and hospital admission costs for babies in the four fertility groups using the CPRD GOLD data and the linked Hospital Episode Statistics (HES) Admitted Patient Care (APC) data. Linear regression was used to compare the care costs in the different groups. Inverse probability weights were generated and applied to adjust for potential bias caused by attrition due to loss to follow-up. MAIN RESULTS AND THE ROLE OF CHANCE: Children born to mothers with no fertility problems had significantly fewer consultations and lower primary care costs compared to the other groups throughout the 10-years' follow up. Regarding hospital costs, children born after ART had significantly higher hospital admission costs in the first year after birth compared to those born to mothers with no fertility problems (difference = £307 (95% CI: 153, 477)). The same pattern was observed in children born after untreated subfertility and ovulation induction. LIMITATIONS, REASONS FOR CAUTION: HFEA linkage uses non-donor data cycles only, and the introduction of consent for data use reduced the availability of HFEA records after 2009. The fertility groups were derived by augmenting HFEA data with evidence from primary care records; however, there remains some potential misclassification of exposure groups. The cost of neonatal critical care is not captured in the HES APC data, which may cause underestimation of the cost differences between the comparison group and the infertility groups. WIDER IMPLICATIONS OF THE FINDINGS: The findings can help anticipate the financial impact on the healthcare system associated with subfertility and ART, particularly as the demand for these treatments grows. STUDY FUNDING/COMPETING INTEREST(S): C.C. and this work were funded by a UK Medical Research Council Career Development Award [MR/L019671/1] and a UK MRC Transition Support Award [MR/W029286/1]. X.H. is an Australia National Health and Medical Research Council (NHMRC) Emerging Leadership Fellow [grant number 2009253]. The authors declare no competing interest. TRIAL REGISTRATION NUMBER: N/A.

Breastfeeding and Childhood Wheeze: Age-Specific Analyses and Longitudinal Wheezing Phenotypes as Complementary Approaches to the Analysis of Cohort Data.

Systematic reviews suggest that breastfeeding is associated with a lower risk of asthma, although marked heterogeneity exists. Using UK Millennium Cohort Study data (n = 10,126 children, born 2000-2002), we examined the association between breastfeeding duration and wheezing in the previous year, first for each age group separately (ages 9 months, 3 years, 5 years, 7 years, and 11 years) and then in terms of a longitudinal wheezing phenotype: "early transient" (wheezing any time up to age 5 years but not thereafter), "late onset" (any time from age 7 years but not beforehand), and "persistent" (any time up to age 5 years and any time from age 7 years). The association between breastfeeding and wheeze varied by age (2-sided P for interaction = 0.0003). For example, breastfeeding for 6-9 months was associated with lower odds of wheezing at ages 9 months, 3 years, and 5 years but less so at ages 7 years and 11 years (adjusted odds ratios = 0.73, 0.78, 0.79, 0.84, 1.06, respectively). There was a strong dose-response relationship for breastfeeding per month and early transient wheeze (adjusted odds ratio for linear trend = 0.961, 95% confidence interval: 0.942, 0.980) but no clear trend for late-onset or persistent wheeze. Our results identified heterogeneity in the association between breastfeeding and wheezing according to age at wheezing and wheezing phenotype.

Association between spousal emotional abuse and reproductive outcomes of women in India: findings from cross-sectional analysis of the 2005-2006 National Family Health Survey.

PURPOSE: Spousal violence against women is a global public health problem. In India, approximately 40% of women report spousal violence. Like physical and sexual violence, emotional violence may be a determinant of women's health. This study explores the association between exposure to spousal emotional abuse and poor reproductive outcomes in Indian women. METHODS: Data on 60,350 women, collected in the Third Indian National Family Health Survey were analysed to assess the impact of spousal emotional abuse on seven reproductive outcomes: age at first birth, number of children, terminated pregnancies, unwanted pregnancies, access to prenatal and skilled delivery care, and breastfeeding. Spousal emotional abuse was assessed using two overlapping constructs: emotional violence and controlling behaviour. Multivariable logistic regression was used for analysis. RESULTS: Spousal emotional violence and controlling behaviour was reported by 16 and 38% of the women, respectively. In unadjusted analyses, spousal emotional violence was associated with all adverse reproductive outcomes, except breastfeeding. Controlling for socio-demographic risk factors attenuated the association, and further adjustment for other forms of violence removed all significant associations. Spousal controlling behaviour was significantly associated with all outcomes, except breastfeeding. The effects remained statistically significant in multivariable regression. CONCLUSIONS: Women's experience of violence may be under-reported. When other forms of violence were adjusted for, emotional violence was not associated with adverse reproductive outcomes, whereas controlling behaviour remained associated with all but one adverse reproductive outcome. Therefore, spousal controlling behaviour requires further investigation as a determinant of reproductive health.

Unplanned pregnancy and subsequent psychological distress in partnered women: a cross-sectional study of the role of relationship quality and wider social support.

BACKGROUND: Research into the impact of unintended pregnancy on the wellbeing of women tends to focus on pregnancies ending in either termination or lone motherhood. Unintended pregnancy is common in partnered women, but little is known about the association between unintended pregnancy and postpartum affective disorders, such as depression and anxiety in this group. Poor relationship quality and lack of social support are considered risk factors for psychological distress (PD). We examined the association between unplanned motherhood and subsequent PD in partnered women, for whom evidence is sparse, accounting for the role of relationship quality and social support. METHODS: Data for 12,462 partnered mothers were drawn from the first survey of Millennium Cohort Study, completed at 9 months postpartum. Women reported whether their baby was planned, and how they felt when they discovered that they were pregnant. Pregnancy intention is categorised as "planned", "unplanned/happy", "unplanned/ambivalent" and "unplanned/unhappy". PD was assessed using the modified 9-item Rutter Malaise Inventory. Social support was measured by a composite score for perceived support, and a measure of actual support from friends and family. Relationship quality was assessed using a modified Golombok-Rust Inventory of Marital State. The effect of pregnancy intention on the odds of PD at 9 months was estimated, adjusting for potential confounding factors. All analyses were weighted for response and design effects. RESULTS: In total 32.8%(weighted) (4343/12462) of mothers reported an unplanned pregnancy: 23.3 wt% (3087) of mothers felt happy, 3.5 wt% (475) ambivalent, and 6.0 wt% (781) unhappy upon discovery. Unplanned pregnancy was associated with a significantly increased odds of PD compared to planned (OR 1.73 (95%CI: 1.53, 1.95)). This was more pronounced among women who reported negative or ambivalent feelings in early pregnancy (OR 2.72 (95%CI:2.17, 3.41) and 2.56 (95%CI:1.95, 3.34), respectively), than those who reported positive feelings (OR 1.39 (95%CI:1.21, 1.60)). Adjustment for relationship quality, in particular, reduced odds of PD after unplanned pregnancy (e.g. from 2.19 (95%C: 1.74, 2.74) to 1.63 (95% CI: 1.29, 2.07 in the unplanned, unhappy group compared to the planned). CONCLUSIONS: A third of partnered mothers reported that their pregnancy was unintended, yet this group is under-researched. Unplanned motherhood was associated with increased risk of PD at 9 months postpartum, particularly among women who felt unhappy or ambivalent at the start. The roles of relationship quality and social support require further investigation, as possible means to intervene and improve maternal wellbeing.

Do various types of prelacteal feeding (PLF) have different associations with breastfeeding duration in Indonesia? A cross-sectional study using Indonesia Demographic and Health Survey datasets.

INTRODUCTION: Prelacteal feeding (PLF) is anything other than breastmilk given to newborns in the first few days of birth and/or before breastfeeding is established. PLF comes in many forms and is known as a challenge to optimal breastfeeding. Interestingly, both breastfeeding and PLF are common in Indonesia. This study investigated the association between PLF (any PLF, formula, honey, water and other milk) and breastfeeding duration. METHODS: This study used Indonesia Demographic and Health Surveys data from 2002, 2007 and 2017. Sample sizes were 5558 (2007), 6268 (2007) and 6227 (2017) mothers whose last child was aged 0-23 months. We used Cox regression survival analysis to assess the association between PLF and breastfeeding duration, estimating hazard ratios (HR) for stopping earlier. RESULTS: Overall PLF was prevalent (59%, 67% and 45% in 2002, 2007 and 2017, respectively), with formula being the most common (38%, 50% and 25%). No association between any PLF and breastfeeding duration in 2002 (HR 0.90 (95% CI 0.70 to 1.16)), but in 2007 and 2017, mothers who gave any PLF were more likely to stop breastfeeding earlier than those who did not (HR 1.33 (95% CI 1.11 to 1.61) and 1.47 (95% CI 1.28 to 1.69), respectively), especially in the first 6 months (HR 2.13 (95% CI 1.55 to 2.92) and 2.07 (95% CI 1.74 to 2.47), respectively). This association was more consistent for milk-based PLF. For example, HR in 2017 was 2.13 (95% CI 1.78 to 2.53) for prelacteal formula and 1.73 (95% CI 1.39 to 2.15) for other milk. The associations were inconsistent for the other PLF types. Prelacteal water showed no association while prelacteal honey showed some association with a longer breastfeeding duration in 2002 and 2007. CONCLUSION: The impact of PLF on breastfeeding duration varied by type. While this study supports current recommendations to avoid PLF unless medically indicated, the potential consequences of different PLF types on breastfeeding outcomes should be clearly communicated to healthcare providers and mothers. Further research should explore the reasons for the high PLF prevalence in this setting.

Associations between maternal body mass index and childhood infections in UK primary care: findings from the Born in Bradford birth cohort study.

OBJECTIVE: To explore associations between maternal body mass index (BMI) in early pregnancy and childhood infections. DESIGN: Birth cohort study linked to primary care records. SETTING: Bradford, UK. PARTICIPANTS: Live singleton births within the Born in Bradford cohort study between 2007 and 2011. EXPOSURES: Maternal BMI in early pregnancy. MAIN OUTCOME MEASURES: The total number of infections between birth and ~14 years of age with subgroup analysis by infection type and age. RESULTS: A total of 9037 mothers and 9540 children were included in the main analysis. 45% of women were of Pakistani ethnicity and 6417 women (56%) were overweight or obese. There was an overall trend for an increasing infection rate with increasing maternal BMI. In adjusted models, only those with obesity grade 2-3 had offspring with significantly higher rates of infection during the first year of life (RR 1.12 (95% CI 1.05 to 1.20)) compared with women of healthy weight. However, by age 5 to <15 years, children born to overweight women (RR 1.09 (95% CI 1.02 to 1.16)), obese grade 1 women (RR 1.18 (95% CI 1.09 to 1.28)) or obese grade 2 women (RR 1.31 (95% CI 1.16 to 1.48)) all had significantly higher rates of infection compared with those born to healthy weight mothers. Respiratory tract and skin/soft tissue infections made up the majority of excess infections. CONCLUSIONS: Maternal BMI was positively associated with rates of offspring infection in this study cohort, and suggests that we should be supporting women to achieve a healthy weight for pregnancy. Future research should investigate whether this is replicated in other populations, whether there is a causal association and the potential mechanisms and areas for intervention.

Ethnic inequities in 6-8 week baby check coverage in England 2006- 2021: a cohort study using the Clinical Practice Research Datalink.

BACKGROUND: Inequities in the coverage of 6-8-week maternal checks, health visitor reviews, and infant vaccinations have been reported in England. Ethnic inequities in 6-8-week baby checks have not been studied nationally. AIM: To examine the effect of maternal ethnicity on 6-8 week baby check coverage in England 2006-2021. DESIGN AND SETTING: This cohort study used electronic health records from primary care in England. METHOD: Baby check coverage was calculated in 16 ethnic groups, by year and region. Risk ratios were estimated using modified Poisson regression. Coverage and timing of baby checks in relation to maternal checks and infant vaccinations by ethnic group were calculated. RESULTS: Ethnic inequities in 6-8 week baby check coverage in England varied by year and region. Coverage increased 2006-2007 to 2015-2016, then stabilised to 80-90% for most groups. Coverage was lowest for Bangladeshi and Pakistani groups 2006-2007 to 2011-2012. In the West Midlands, coverage was lowest at approximately 60% for four groups: Bangladeshi, Caribbean, African, and Any other Black, African or Caribbean background. In the North West, coverage was lowest for Bangladeshi (65.3%) and Pakistani (69.2%) groups. These patterns remained after adjusting for other factors and persisted over time. Coverage was highest in those whose mothers received a maternal check and those who received at least one dose of 8-week infant vaccinations. CONCLUSION: Coordinated action at the level of integrated commissioning boards, primary care networks, and GP practices is required to better understand the reasons behind these inequities and redress the persistent disparities in 6-8 week baby check coverage.

Anxiety in couples undergoing IVF: evidence from E-Freeze randomised controlled trial.

STUDY QUESTION: What are the risk factors and impacts of anxiety in women and men in heterosexual couples undergoing IVF as part of a randomised trial, with a delay in embryo transfer in one arm? SUMMARY ANSWER: Duration of infertility, ethnicity, and male partner's anxiety levels were associated with women's anxiety at the start of treatment, while initial anxiety score, partner's anxiety score at embryo transfer, ethnicity, and clinic location were associated with women's anxiety levels at embryo transfer; although women undergoing IVF were more anxious than their partners for slightly different reasons, their self-reported state anxiety was not associated with achieving clinical pregnancy, nor with switching from delayed frozen embryo transfer to fresh embryo transfer in an IVF trial. WHAT IS KNOWN ALREADY: Use of IVF treatment continues to rise and patients undergoing IVF are anxious. Participating in a randomised controlled trial (RCT) with uncertainty of arm randomisation might increase their anxiety, while a delay in treatment may add further to anxiety. STUDY DESIGN SIZE DURATION: A mixed methods study was conducted using data from the multi-centre E-Freeze RCT cohort conducted across 13 clinics in the UK from 2016 to 2019. A regression analysis on anxiety scores of couples undergoing the IVF trial and a qualitative analysis of participant questionnaires were performed. PARTICIPANTS/MATERIALS SETTING METHODS: Six hundred and four couples participating in the E-Freeze trial, who had at least one useable State-Trait Anxiety Inventory (STAI) State Anxiety subscale (STAI-S) standardised self-report questionnaire for at least one of the partners, were included in the study. STAI-S scores were measured at consent for trial (T1) and again at embryo transfer (T2). Linear and log-binomial regression were used to explore the association between characteristics and STAI-S scores, and the associations between STAI-S scores and non-compliance and clinical pregnancy, respectively. Responses to the open text question were qualitatively analysed inductively using content analysis. MAIN RESULTS AND THE ROLE OF CHANCE: Women's STAI-S scores at T1 (consent) were associated with their ethnicity, duration of infertility, and their male partner's STAI-S score at T1. Women's STAI-S scores at T2 (embryo transfer) were associated with their ethnicity, location of fertility clinic, their STAI-S score at consent, and their male partner's STAI-S score at embryo transfer. The adjusted coefficient (95% CI) for women's STAI-S scores at T2 was -4.75 (-7.29, -2.20, P < 0.001) for ethnic minority versus White, -2.87 (-4.85, -0.89, P = 0.005) for Scotland versus England, 0.47 (0.37, 0.56, P < 0.001) for each point increase in their own score at T1, and 0.30 (0.21, 0.40, P < 0.001) for each point increase in their male partner's score at T2. On average, women had higher STAI-S scores than men at both time points, and a larger increase of scores between the two time points. However, women's STAI-S scores were not associated with either non-compliance with trial allocation in the 'freeze-all' trial arm, or with chances of pregnancy. Both partners, but particularly women, described feeling anxious about the outcome of IVF, with women carrying the added worry of believing that feeling stressed might itself affect the outcome. Participants highlighted the important role of support from staff in helping them to manage their anxiety. LIMITATIONS REASONS FOR CAUTION: Data were not available on education level or social support, which might influence anxiety scores. Men's baseline characteristics were not collected. WIDER IMPLICATIONS OF THE FINDINGS: Identifying couples at increased risk of emotional distress may be improved by using standardised anxiety measures at the start of the fertility treatment. Women can be reassured that their self-reported state anxiety does not affect their chances of achieving clinical pregnancy through IVF, and this may help to reduce anxiety levels. The psychological wellbeing and experiences of couples undergoing IVF could be supported by patient-centred care: making information about the whole process of treatment and choices available to both partners in accessible formats; ensuring interactions with staff are kind and supportive; and acknowledging and addressing the different concerns of women undergoing IVF and their partners. STUDY FUNDING/COMPETING INTERESTS: This study was an NIHR HTA (National Institute for Health and Care Research Health Technology Assessment) funded study. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: ISRCTN registry: ISRCTN61225414.

Child mental health and income gradient from early childhood to adolescence: Evidence from the UK.

Background: Children from low income families are likely to have poorer mental health than their more affluent peers. However, it is unclear how this association varies at different developmental stages and what the potential underpinning mechanisms are. This study investigates the relationship between family income and mental health problems from early childhood to adolescence in the UK, and examines the potential mediating role of family-related factors over time. Methods: Data were drawn from the UK Millennium Cohort Study at ages 3, 5, 7, 11, 14 and 17 years. Child mental health was measured by the Strengths and Difficulties Questionnaire Total Difficulties Score, and the Internalising and Externalising subscales. Family income was operationalised as permanent income. Cross-sectional analyses were conducted at each age to examine the association between income and mental health problems, and to examine potential mechanisms based on the Parental Stress and Parental Investment theories. Results: The samples included 8096 children aged up to 14 years, of which 5667 remained in the study at age 17. Results indicated a statistically significant association between lower family income and poorer mental health in all age groups after adjusting for confounding factors. The strength of the association was reduced after adjustment for Parental Stress and Parental Investment factors, with the larger attenuation driven by Parental Stress factors in most cases. Fully adjusted models suggested an increased independent association between maternal psychological distress and children's mental health as children grew older. Conclusions: While lower family income is associated with a child's poorer mental health, much of this association is explained by other factors such as maternal psychological distress, and therefore the direct association is relatively small. This suggests that policies targeting income redistribution may reduce child mental health problems, and also benefit the wider family, reducing the prevalence of other associated risk factors.

Association between breastfeeding duration and educational achievement in England: results from the Millennium Cohort Study.

OBJECTIVE: To evaluate the association between breastfeeding duration and educational outcomes at the end of secondary education among children from the Millennium Cohort Study. DESIGN: Cohort study comparing school results at age 16 according to breastfeeding duration. SETTING: England. PARTICIPANTS: Children born in 2000-2002 (nationally representative sample). EXPOSURE: Self-reported breastfeeding duration (categorised). MAIN OUTCOME MEASURES: Standardised school assessments taken at the end of secondary education (General Certificate of Secondary Education (GCSEs), marked 9-1) in English and Mathematics, categorised as: 'fail, marks <4', 'low pass, marks 4-6' and 'high pass, marks ≥7 (equivalent to A-A*)'. Additionally, overall achievement was measured using the 'attainment 8' score (adding the marks of eight GCSEs, English and Mathematics double weighted; 0-90). RESULTS: Approximately 5000 children were included. Longer breastfeeding was associated with better educational outcomes. For example, after full adjustment for socioeconomic markers and maternal cognitive ability, in comparison with children who were never breastfed, those who were breastfed for longer were more likely to have a high pass in their English and Mathematics GCSEs, and less likely to fail the English GCSE (but not the Mathematics GCSE). Additionally, compared with those never breastfed, those breastfed for at least 4 months had, on average, a 2-3 point higher attainment 8 score (coefficients: 2.10, 95% CI 0.06 to 4.14 at 4-6 months; 2.56, 95% CI 0.65 to 4.47 at 6-12 months and 3.09, 95% CI 0.84 to 5.35 at ≥12 months). CONCLUSIONS: A longer breastfeeding duration was associated with modest improvements in educational outcomes at age 16, after controlling for important confounders.

Ethnic inequities in routine childhood vaccinations in England 2006-2021: an observational cohort study using electronic health records.

Background: Population groups that are underserved by England's childhood vaccination programme must be identified to address the country's declining vaccination coverage. We examined routine childhood vaccination coverage in England by maternal ethnicity between 2006 and 2021. Methods: We created first, second and fifth birthday cohorts using mother-child linked electronic health records from the Clinical Practice Research Datalink (CPRD) Aurum. After validation against the UK Health Security Agency (UKHSA) and National Health Service England (NHSE) annual statistical reports, we described vaccination coverage for each vaccine by ethnicity and year. We used modified Poisson regression to analyse the effect of ethnicity on receiving the primary and full course of each vaccine. Findings: Up to 1,170,804 children born after 1 April 2006 were included in the first birthday cohort, reducing to 645,492 by the fifth birthday. Children were followed up until 31 March 2021 at the latest. Children born to mothers in 9 minority ethnic groups and those of unknown ethnicity had lower vaccination coverage (61.3-97.5%) than the White British group (79.9-97.8%) for all vaccines. Indian, Pakistani, Bangladeshi, Chinese, Any other Asian background, and White and Asian ethnic groups had similar vaccination coverage to the White British group (above 90% for most vaccines in most years). Inequities particularly affected the Caribbean group (e.g. 61% coverage for the 6/5/4-in-1 full course in 2020-21 by children's fifth birthday; RR 0.66, 95% CI 0.6-0.74 compared with the White British group) and Any other Black, African and Caribbean background (e.g. coverage 68% for the MMR primary course in 2020-21; RR 0.71, 95% CI 0.64-0.78). These inequities widened over the study period. For example, the absolute difference in coverage between the Caribbean and White British groups for the full course of MMR increased from 12% in 2011-12 to 22% in 2019-20. These inequities remained even after accounting for sociodemographic, maternal and birth related factors, and also widened from primary course to full course. Interpretation: Our findings suggest that urgent policy action is needed to address the ethnic inequities throughout England's routine childhood vaccination programme, which have been worsening over time. Funding: University of Oxford Clarendon Fund, St Cross College and Nuffield Department of Population Health.

Ethnic differences and inequities in paediatric healthcare utilisation in the UK: a scoping review.

BACKGROUND: Despite the increased policy attention on ethnic health inequities since the COVID-19 pandemic, research on ethnicity and healthcare utilisation in children has largely been overlooked. OBJECTIVES: This scoping review aimed to describe and appraise the quantitative evidence on ethnic differences (unequal) and inequities (unequal, unfair and disproportionate to healthcare needs) in paediatric healthcare utilisation in the UK 2001-2021. METHODS: We searched Embase, Medline and grey literature sources and mapped the number of studies that found differences and inequities by ethnic group and healthcare utilisation outcome. We summarised the distribution of studies across various methodological parameters. RESULTS: The majority of the 61 included studies (n=54, 89%) identified ethnic differences or inequities in paediatric healthcare utilisation, though inequities were examined in fewer than half of studies (n=27, 44%). These studies mostly focused on primary and preventive care, and depending on whether ethnicity data were aggregated or disaggregated, findings were sometimes conflicting. Emergency and outpatient care were understudied, as were health conditions besides mental health and infectious disease. Studies used a range of ethnicity classification systems and lacked the use of theoretical frameworks. Children's ethnicity was often the explanatory factor of interest while parent/caregiver ethnicity was largely overlooked. DISCUSSION: While the current evidence base can assist policy makers to identify inequities in paediatric healthcare utilisation among certain ethnic groups, we outline recommendations to improve the validity, generalisability and comparability of research to better understand and thereby act on ethnic inequities in paediatric healthcare.

Gestational age and hospital admission costs from birth to childhood: a population-based record linkage study in England.

OBJECTIVE: To examine the association between gestational age at birth and hospital admission costs from birth to 8 years of age. DESIGN: Population-based, record linkage, cohort study in England. SETTING: National Health Service (NHS) hospitals in England, UK. PARTICIPANTS: 1 018 136 live, singleton births in NHS hospitals in England between 1 January 2005 and 31 December 2006. MAIN OUTCOME MEASURES: Hospital admission costs from birth to age 8 years, estimated by gestational age at birth (<28, 28-29, 30-31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 and 42 weeks). RESULTS: Both birth admission and subsequent admission hospital costs decreased with increasing gestational age at birth. Differences in hospital admission costs between gestational age groups diminished with increasing age, particularly after the first 2 years following birth. Children born extremely preterm (<28 weeks) and very preterm (28-31 weeks) still had higher average hospital admission costs (£699 (95% CI £419 to £919) for <28 weeks; £434 (95% CI £305 to £563) for 28-31 weeks) during the eighth year of life compared with children born at 40 weeks (£109, 95% CI £104 to £114). Children born extremely preterm had the highest 8-year cumulative hospital admission costs per child (£80 559 (95% CI £79 238 to £82 019)), a large proportion of which was incurred during the first year after birth (£71 997 (95% CI £70 866 to £73 097)). CONCLUSIONS: The association between gestational age at birth and hospital admission costs persists into mid-childhood. The study results provide a useful costing resource for future economic evaluations focusing on preventive and treatment strategies for babies born preterm.

Breastfeeding is associated with improved child cognitive development: a population-based cohort study.

OBJECTIVE: To assess the association between breastfeeding and child cognitive development in term and preterm children. STUDY DESIGN: We analyzed data on white singleton children from the United Kingdom Millennium Cohort Study. Children were grouped according to breastfeeding duration. Results were stratified by gestational age at birth: 37 to 42 weeks (term, n = 11,101), and 28 to 36 weeks (preterm, n = 778). British Ability Scales tests were administered at age 5 years (naming vocabulary, pattern construction, and picture similarities subscales). RESULTS: The mean scores for all subscales increased with breastfeeding duration. After adjusting for confounders, there was a significant difference in mean score between children who were breastfed and children who were never breastfed: in term children, a two-point increase in score for picture similarities (when breastfed ≥ 4 months) and naming vocabulary (when breastfed ≥ 6 months); in preterm children, a 4-point increase for naming vocabulary (when breastfed ≥ 4 months) and picture similarities (when breastfed ≥ 2 months) and a 6-point increase for pattern construction (when breastfed ≥ 2 months). These differences suggest that breastfed children will be 1 to 6 months ahead of children who were never breastfed. CONCLUSIONS: In white, singleton children in the United Kingdom, breastfeeding is associated with improved cognitive development, particularly in children born preterm.

To what extent does confounding explain the association between breastfeeding duration and cognitive development up to age 14? Findings from the UK Millennium Cohort Study.

BACKGROUND: Breastfeeding duration is associated with improved cognitive development in children, but it is unclear whether this is a causal relationship or due to confounding. This study evaluates whether the observed association is explained by socioeconomic position (SEP) and maternal cognitive ability. METHODS: Data from 7,855 singletons born in 2000-2002 and followed up to age 14 years within the UK Millennium Cohort Study were analysed. Mothers reported breastfeeding duration, and children's cognitive abilities were assessed at 5, 7, 11, and 14 years using validated measures. Standardised verbal (age 5 to 14) and spatial (age 5 to 11) cognitive scores were compared across breastfeeding duration groups using multivariable linear mixed-effects models (repeated outcome measures). RESULTS: At all ages, longer breastfeeding durations were associated with higher cognitive scores after accounting for the child's own characteristics. Adjustment for SEP approximately halved the effect sizes. Further adjustment for maternal cognitive scores removed the remaining associations at age 5, but not at ages 7, 11 and 14 (e.g.: verbal scores, age 14; breastfed ≥12 months vs never breastfed: 0.26 SD; 95%CI: 0.18, 0.34). CONCLUSION: The associations between breastfeeding duration and cognitive scores persist after adjusting for SEP and maternal cognitive ability, however the effect was modest.

Trends and inequalities in breastfeeding continuation from 1 to 6 weeks: findings from six population-based British cohorts, 1985-2010.

BACKGROUND: Understanding inequalities in breastfeeding practices may help to explain the UK's persistently low breastfeeding rates. A recent study using the quinquennial UK Infant Feeding Surveys (IFS) found that sociodemographic inequalities in breastfeeding initiation persisted between 1985 and 2010. The present study investigates the sociodemographic inequalities in breastfeeding continuation at 6 weeks after birth among mothers who initiated and maintained breastfeeding at 1 week in 1985-2010. METHODS: Data were drawn from the 1985 to 2010 IFS and restricted to mothers who were breastfeeding at 1 week after birth. Time trends in the proportion of mothers in each sociodemographic group were examined. Logistic regression was used to estimate associations between breastfeeding at 6 weeks and sociodemographic factors, adjusting for confounders. Heterogeneity test was used to assess changes in these associations over time. RESULTS: Sociodemographic inequalities in breastfeeding continuation at 6 weeks persisted over the 25-year period. In most survey years, mothers were most likely to breastfeed at 6 weeks if they were 30 or older versus under 25 (OR 1.49-1.99 across survey years, I2 = 0%, heterogeneity P = 0.45); completed full-time education over age 18 compared to 18 or younger (OR 1.56-2.51, I2 = 58.7%, P = 0.03); or of Black, Asian, Mixed, or other ethnicity compared to White (OR 1.45-2.48, I2 = 44.8%, P = 0.16). CONCLUSIONS: Among mothers breastfeeding at 1 week, those who were younger, White or had fewer years of full-time education were at greatest risk of discontinuing before 6 weeks. This risk persisted over time and was independent of their high risk of not initiating breastfeeding.

Evidence of disparities in the provision of the maternal postpartum 6-week check in primary care in England, 2015-2018: an observational study using the Clinical Practice Research Datalink (CPRD).

BACKGROUND: A maternal postpartum 6-week check (SWC) with a general practitioner (GP) is now considered an essential service in England, a recent policy change intended to improve women's health. We aimed to provide an up-to-date snapshot of the prevalence of SWC prior to the policy change as a baseline, and to explore factors associated with having a late or no check. METHODS: We conducted a cohort study using primary care records in England (Clinical Practice Research Datalink (CPRD)). 34 337 women who gave birth between 1 July 2015 and 30 June 2018 and had ≥12 weeks of follow-up post partum were identified in the CPRD Pregnancy Register. The proportion who had evidence of an SWC with a GP was calculated, and regression analysis was used to assess the association between women's characteristics and risks of a late or no check. RESULTS: Sixty-two per cent (95% CI 58% to 67%) of women had an SWC recorded at their GP practice within 12 weeks post partum, another 27% had other consultations. Forty per cent had an SWC at the recommended 6-8 weeks, 2% earlier and 20% later. A late or no check was more common among younger women, mothers of preterm babies or those registered in more deprived areas. CONCLUSIONS: Nearly 40% of women did not have a postpartum SWC recorded. Provision or uptake was not equitable; younger women and those in more deprived areas were less likely to have a record of such check, suggesting postpartum care in general practice may be missing some women who need it most.

How women with obsessive compulsive disorder experience maternity care and mental health care during pregnancy and postpartum: A systematic literature review.

INTRODUCTION: Obsessive Compulsive Disorder has a higher prevalence in pregnancy and postpartum than in the general population. Experiences of maternity care and mental health care can impact the health and wellbeing of perinatal women. The aim of this review was to synthesize evidence on the experiences of maternity care and mental health care for women with OCD during pregnancy and postpartum. METHODS: Studies were systematically reviewed by two independent reviewers after identification in MEDLINE, Embase, PsycINFO, Global Health, CINAHL, the Cochrane Library, Web of Science and grey literature searches (last searched October 2021). Papers meeting pre-specified inclusion criteria were extracted using a pre-determined extraction sheet and were quality assessed. Thematic synthesis was conducted. RESULTS: 19 papers reporting 18 studies describing 33 participants were included. Three descriptive themes were found: experiences of barriers to treatment and care, experiences of treatment/care decision making and experiences of treatment and care. Three analytic themes were found demonstrating tensions: keeping baby healthy vs keeping mother healthy, keeping baby safe vs keeping mother safe, and normal perinatal experience vs not normal perinatal experience. LIMITATIONS: Despite an inclusive search strategy, available data was limited. 17 of the studies were case studies that were poor in quality. Synthesis and subsequent findings were limited. CONCLUSIONS: There were significant literature gaps for all aspects of care but particularly around experiences of maternity and pharmacological care. Tensions that could impact the experience of care need to be carefully balanced to ensure that women with OCD get the care that they need.

The association between conception history and subsequent postpartum depression and/or anxiety: Evidence from the Clinical Practice Research Datalink 1991-2013.

BACKGROUND: Infertility, and fertility treatment, are associated with psychological distress that may influence subsequent mental health including postpartum depression and anxiety. METHODS: Data for women who had a livebirth between 1991 and 2013 were drawn from the Clinical Practice Research Datalink. Conception history prior to their first recorded birth was categorised as 'no fertility problems', 'untreated subfertility', ovulation induction (OI), and assisted reproductive technologies (ART). Depression and/or anxiety in the 12 months postpartum were identified using records of diagnoses, symptoms, and prescriptions. Prevalence was compared, and odds ratios estimated using multivariable logistic regression. RESULTS: Of 235,127 mothers, 31,947 (13.6%) had evidence of postpartum depression and/or anxiety. Mothers in the ART group had 22% lower odds of postnatal depression and/or anxiety compared to mothers in the fertile group (OR 0.78; 95% CI [0.70-0.86]; p < 0.0001). Accounting for prior mental health, lifestyle, sociodemographic and pregnancy-related factors reduced the strength of the association (aOR 0.87; 95% CI [0.78-0.97]; p = 0.01). There were no significant associations observed in the untreated subfertility or OI groups. LIMITATIONS: As in any analysis of routine data, the quality of recording is important and some information was unavailable (e.g. education, social support). CONCLUSIONS: Women with a history of subfertility, OI or ART treatment were not at increased risk of postpartum depression and/or anxiety compared to those with no fertility problems. It is important to explore whether women who underwent ART are less likely to experience depression/anxiety or do not seek help when needed, with implications for their health and care.