Recognizing Excellence in Maternal and Child Health (MCH) Epidemiology: The National MCH Epidemiology Awards.

PURPOSE: Professionals in the field of maternal and child health (MCH) epidemiology are publicly recognized by the Coalition for Excellence in MCH Epidemiology representing 16 national MCH agencies and organizations. DESCRIPTION: During the CityMatCH Leadership and MCH Epidemiology Conference, the national awards are presented to public health professionals for improving the health of women, children, and families. The awards have evolved over the last two decades with focus on awardees that represent more types of MCH public health professionals. ASSESSMENT: Since 2000, the Coalition has presented 111 national awards in the areas of advancing knowledge, effective practice, outstanding leadership, excellence in teaching and mentoring, early career professional achievement, and lifetime achievement. Effective practice awards were most often presented at 45 awards, followed by early career professional achievement with 20. The awardees varied by place of employment with 37 employed at academic institutions, 33 in federal government positions, 32 in state or county government, seven in non-profit and two in clinical organizations. Awards were almost equally distributed by gender with 49 presented to women and 48 to men. Assessment of career advancement among previous awardees and acknowledging workforce challenges are gaps identified within the national awards process. CONCLUSION: Recognition of deserving MCH professionals sets the standard for those entering the field of MCH epidemiology and offers opportunity to recognize those who have built capacity and improved the health of women, children, and families.

Maternal weight and paediatric health use: mediating role of adverse birth outcomes: a retrospective cohort study.

BACKGROUND: Maternal pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) above or below recommendations have been associated with increased paediatric health service utilization as well as increased risk of adverse birth outcomes, including small for gestational age (SGA) and preterm birth (PTB). SGA and PTB are associated with numerous adverse health outcomes in the child, including delayed growth, motor and cognitive impairment. Previous research has identified birth weight and gestational age on the causal pathway in the association between maternal pre-pregnancy BMI and child hospital admissions, there are no studies to date to quantify this relationship across other areas of health service utilization, nor the impact of gestational weight gain. This study aimed to assess if SGA or PTB partially explain the association between maternal weight and paediatric health service utilization. METHODS: The study population consisted of all women who delivered a singleton, live infant in Ontario between 2012 and 2014, and was assembled from data contained in the provincial birth registry. Health service utilization over the first 24 months following birth was examined by linking data from the registry with other provincial health administrative databases housed at ICES. The mediating roles of PTB and SGA were assessed using the Baron-Kenny method and causal mediation analysis. RESULTS: A total of 204,162 infants were included in the analysis of maternal pre-pregnancy BMI and 171,127 infants were included in the GWG analysis. The small magnitude of association between maternal BMI and paediatric health service utilization impacted our ability to estimate the indirect effect of maternal BMI through adverse birth outcomes (adjusted indirect effect = 0.00). 56.7% of the association between below recommended GWG and increased hospitalizations was attributed to PTB, while 6.8% of the association was attributed to SGA. CONCLUSION: Paediatric hospitalizations may be partially attributable to PTB and SGA in children born to mothers with below-recommended GWG. However, maternal weight also appears to be related to increased paediatric health service utilization independent of PTB and SGA.

Maternal smoking during pregnancy and type 1 diabetes in the offspring: a nationwide register-based study with family-based designs.

BACKGROUND: Maternal smoking during pregnancy was reported to be associated with a reduced risk of type 1 diabetes in the offspring. We investigated whether this association is consistent with a causal interpretation by accounting for familial (shared genetic and environmental) factors using family-based, quasi-experimental designs. METHODS: We included 2,995,321 children born in Sweden between 1983 and 2014 and followed them for a diagnosis of type 1 diabetes until 2020 through the National Patient, Diabetes and Prescribed Drug Registers. Apart from conducting a traditional cohort study, we performed a nested case-control study (quasi-experiment) comparing children with type 1 diabetes to their age-matched siblings (or cousins). Information on maternal smoking during pregnancy was retrieved from the Swedish Medical Birth Register. Multivariable adjusted Cox proportional hazards regression and conditional logistic regression were used. RESULTS: A total of 18,617 children developed type 1 diabetes, with a median age at diagnosis of 9.4 years. The sibling and cousin comparison design included 14,284 and 7988 of these children, respectively. Maternal smoking during pregnancy was associated with a 22% lower risk of offspring type 1 diabetes in the full cohort (hazard ratio 0.78, 95% confidence interval [CI] 0.75-0.82). The corresponding odds ratio was 0.78 (95% CI 0.69-0.88) in the sibling and 0.72 (95% CI 0.66-0.79) in the cousin comparison analysis. CONCLUSIONS: This nationwide, family-based study provides support for a protective effect of maternal smoking on offspring type 1 diabetes. Mechanistic studies are needed to elucidate the underlying pathways behind this link.

Pregnancy outcomes after preterm premature rupture of membranes: The Japan Environment and Children's Study.

AIM: To evaluate the pregnancy outcomes of preterm premature rupture of membranes (preterm PROM; PPROM) by gestational age. METHODS: This cohort study analyzed data from the Japan Environment and Children's Study. Pregnancy outcomes were documented using descriptive statistics. Logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of complications. RESULTS: Data were collected for 104 062 fetuses, and 99 776 were eligible for inclusion. The incidences of early (18-23 weeks) and late (24-36 weeks) PPROM were 0.1% (n = 102) and 1.2% (n = 1205), respectively. Of the 1307 cases, 66 (5.0%) resulted in miscarriage or stillbirth. Overall, 85.6% (1119/1307) resulted in preterm births, and 9.3% (122/1307) in term births. There was a higher incidence of oligohydramnios (OR 6.82, 95% CI 4.07, 11.4; OR 2.42, 95% CI 1.72, 3.40), intrauterine infection (OR 11.9, 95% CI 7.06, 19.9; OR 4.39, 95% CI 3.01, 6.41), cesarean delivery (OR 3.31, 95% CI 2.32, 4.71; OR 1.34, 95% CI 0.97, 1.85), placental abruption (OR 5.57, 95% CI 2.30, 13.5; OR 5.40, 95% CI 3.58, 8.14), and 5-min Apgar score <7 (OR 35.3, 95% CI 21.5, 57.9; OR 2.66, 95% CI 1.75, 4.05) for early and late, compared to no, PPROM, respectively. Miscarriage or stillbirth was higher in early (OR 5.84, 95% CI 3.72, 9.15) and lower in late (OR 0.21, 95% CI 0.06, 0.68) compared to those without PPROM. CONCLUSIONS: This study described the epidemiology of pregnancy outcomes of early (occurring at the limit of viability) and late PPROM.

Congenital Heart Defects and the Risk of Spontaneous Preterm Birth.

OBJECTIVES: To estimate the association between major types of congenital heart defects (CHD) and spontaneous preterm birth, and to assess the potential underlying mechanisms. STUDY DESIGN: This nationwide, registry-based study included a cohort of all singleton pregnancies in Denmark from 1997 to 2013. The association between CHD and spontaneous preterm birth was estimated by multivariable Cox regression, adjusted for potential confounders. The following potential mechanisms were examined: maternal genetics (sibling analyses), polyhydramnios, preterm prelabor rupture of membranes, preeclampsia, and indicators of fetal and placental growth. RESULTS: The study included 1 040 474 births. Compared with the general population, CHD was associated with an increased risk of spontaneous preterm birth, adjusted hazard ratio 2.1 (95% CI, 1.9-2.4). Several subtypes were associated with increased risks, including pulmonary stenosis combined with a septal defect, 5.2 (95% CI, 3.7-7.5); pulmonary stenosis or atresia, 3.1 (95% CI, 2.4-4.1); tetralogy of Fallot 2.5 (95% CI, 1.6-3.8); coarctation or interrupted aortic arch 2.2 (95% CI, 1.5-3.2); and hypoplastic left heart syndrome, 2.0 (95% CI, 1.0-4.1). Overall, preterm prelabor rupture of membranes mediated more than one-half of the association. Maternal genetics, polyhydramnios, or indicators of fetal or placental growth did not explain the reported associations. CONCLUSIONS: CHD, especially right ventricular outflow tract obstructions, were associated with an increased risk of spontaneous preterm birth. The risk was carried by the CHD and not by maternal genetics. Moreover, preterm prelabor rupture of membranes was identified as a potential underlying mechanism.

Risk factors for very preterm delivery out of a level III maternity unit: The EPIPAGE-2 cohort study.

BACKGROUND: Regionalisation programmes aim to ensure that very preterm infants are born in level III units (inborn) through antenatal referral or transfer. Despite widespread knowledge about better survival without disability for inborn babies, 10%-30% of women deliver outside these units (outborn). OBJECTIVE: To investigate risk factors associated with outborn deliveries and to estimate the proportion that were probably or possibly avoidable. METHODS: We used a national French population-based cohort including 2205 women who delivered between 24 and 30+6  weeks in 2011. We examined risk factors for outborn delivery related to medical complications, antenatal care, sociodemographic characteristics and living far from a level III unit using multivariable binomial regression. Avoidable outborn deliveries were defined by pregnancy risk (obstetric history, antenatal hospitalisation) and time available for transfer. RESULTS: 25.0% of women were initially booked in level III, 9.1% were referred, 49.8% were transferred, and 16.1% had outborn delivery. Risk factors for outborn delivery were gestational age <26 weeks (adjusted relative risk (aRR) 1.37, 95% confidence interval (CI) 1.13, 1.66), inadequate antenatal care (aRR 1.39, 95% CI 1.10, 1.81), placental abruption (aRR 1.66, 95% CI 1.27, 2.17), and increased distance to the closest level III unit ((aRR 2.79, 95% CI 2.00, 3.92) in the 4th versus 1st distance quartile). Among outborn deliveries, 16.7% were probably avoidable, and 25.6% possibly avoidable, which could increase the proportion of inborn deliveries between 85.9% and 92.9%. Avoidable outborn deliveries were mainly associated with gestational age, intrauterine growth restriction, preterm premature rupture of membranes, and haemorrhage, but not distance. CONCLUSIONS: Our study identified some modifiable risk factors for outborn delivery; however, when regionalised care relies heavily on antenatal transfer, as it does in France, only some outborn deliveries may be prevented. Earlier referral of high-risk women will be needed to achieve full access to tertiary care.

The association between threatened preterm labour and perinatal outcomes at term: a population-based cohort study.

OBJECTIVE: To estimate the association between threatened preterm labour (TPTL) and perinatal outcomes of infants born at term. DESIGN: A population-based cohort study of perinatal outcomes following TPTL <37 weeks of gestation with delivery at term. SETTING: Nova Scotia, Canada. POPULATION: All non-anomalous, singleton pregnancies ≥37 weeks of gestation without antepartum haemorrhage from 1988 to 2019. METHODS: Using data from the Nova Scotia Atlee Perinatal Database, TPTL was defined as pregnancies with a hospital admission between 20 and 37 weeks of gestation, with a diagnosis code denoting TPTL with administration of antenatal corticosteroids, or with administration of any tocolysis. Poisson regression models were used to estimate the risk ratios (RR) with 95% CI of maternal and perinatal outcomes in women who had an episode of TPTL relative to those who did not. MAIN OUTCOME MEASURES: Birthweight for gestational age below the tenth centile and a composite of perinatal mortality or severe perinatal morbidity. RESULTS: Of 256 599 term deliveries meeting the inclusion criteria, 2278 (0.9%) involved TPTL. The risks of the primary outcomes were higher among those with TPTL relative to those without: birthweight for gestational age below the tenth centile (RR 1.24, 95% CI 1.11-1.39) and the composite of perinatal mortality/severe perinatal morbidity (RR 1.33, 95% CI 1.15-1.54). CONCLUSIONS: Although the prevalence of TPTL in term deliveries is low, affected pregnancies are at increased risk for adverse perinatal outcomes. Increased fetal surveillance should be considered in the management of pregnancies affected by TPTL.

The impact of cesarean delivery on infant DNA methylation.

BACKGROUND: Mounting evidence suggests that cesarean delivery may have a long-lasting effect on infant health. But the underlying mechanisms remain unclear. This study aims to examine whether cesarean delivery on maternal request without any medical indications (CDMR) impacts DNA methylation status in the umbilical cord blood of the infant. METHODS: A cross-sectional study was conducted in Shanghai, China. A total of 70 CDMR and 70 vaginal deliveries (VD) were recruited in 2012. The cord blood DNA methylation status was measured in 30 CDMR and 30 VD newborns using Illumina Infinium Human Methylation 450 K BeadChip. To validate the results, the cord blood DNA methylation status was measured in another 40 CDMR and 40 VD newborns using targeted bisulfite sequencing assay. A total of 497 CpG sites from 40 genes were included in the analysis. RESULTS: A total of 165 differentially methylated positions (DMPs) exhibited differences in DNA methylation by 10% or more between the CDMR and VD groups, many of which were related to the development of the immune system. Based on the targeted bisulfite sequencing assay, 16 genes (16/22, 72.7%) had higher methylation level in the CDMR group than the VD group. Among them, 5 genes were related to the immune system. After considering the estimation of cell type proportions, there was few significant differences in DNA methylation between CDMR and VD groups. CONCLUSIONS: The DMPs identified between CDMR and VD groups might be largely explained by the cell type proportions. Further studies are needed to examine DNA methylation in each cell type separately.

Risk factors for the recurrence of obstetrical anal sphincter injury and the role of a mediolateral episiotomy: an analysis of a national registry.

OBJECTIVE: The assessment of risk factors, including mediolateral episiotomy (MLE), for the recurrence of obstetric anal sphincter injury (rOASI). DESIGN: Population-based cohort study. SETTING: Data from the nationwide database of the Dutch Perinatal Registry (Perined). POPULATION: A cohort of 391 026 women at term, of whom 9943 had an OASI in their first delivery and had a second vaginal delivery of a liveborn infant in cephalic position. METHODS: Possible risk factors were tested for statistical significance using univariate and multivariate logistic regression analysis. MAIN OUTCOME MEASURES: Rate of rOASI. RESULTS: The rate of rOASI was 5.8%. Multivariate analysis identified a birthweight of ≥4000 g (adjusted OR, aOR, 2.1, 95% CI 1.6-2.6) and a duration of second stage of ≥30 minutes (aOR 1.8, 95% CI 1.4-2.3) as statistically significant risk factors for rOASI. Mediolateral episiotomy was associated with a statistically significant lower rate of rOASI in spontaneous vaginal delivery (SVD) (aOR 0.4, 95% CI 0.3-0.5) and in operative vaginal delivery (OVD) (aOR 0.2, 95% CI 0.1-0.5). CONCLUSIONS: Women with a history of OASI have a higher rate of OASI in their next delivery. Duration of the second stage of ≥30 minutes and a birthweight of ≥4000 g are significantly associated with an increased rate of rOASI. Mediolateral episiotomy is associated with a significantly lower rate of rOASI in both SVD and OVD. TWEETABLE ABSTRACT: Mediolateral episiotomy is associated with a significant lower recurrence rate of OASI in women with an OASI in their first delivery.

Revisiting the Table 2 fallacy: A motivating example examining preeclampsia and preterm birth.

BACKGROUND: A "Table Fallacy," as coined by Westreich and Greenland, reports multiple adjusted effect estimates from a single model. This practice, which remains common in published literature, can be problematic when different types of effect estimates are presented together in a single table. The purpose of this paper is to quantitatively illustrate this potential for misinterpretation with an example estimating the effects of preeclampsia on preterm birth. METHODS: We analysed a retrospective population-based cohort of 2 963 888 singleton births in California between 2007 and 2012. We performed a modified Poisson regression to calculate the total effect of preeclampsia on the risk of PTB, adjusting for previous preterm birth. pregnancy alcohol abuse, maternal education, and maternal socio-demographic factors (Model 1). In subsequent models, we report the total effects of previous preterm birth, alcohol abuse, and education on the risk of PTB, comparing and contrasting the controlled direct effects, total effects, and confounded effect estimates, resulting from Model 1. RESULTS: The effect estimate for previous preterm birth (a controlled direct effect in Model 1) increased 10% when estimated as a total effect. The risk ratio for alcohol abuse, biased due to an uncontrolled confounder in Model 1, was reduced by 23% when adjusted for drug abuse. The risk ratio for maternal education, solely a predictor of the outcome, was essentially unchanged. CONCLUSIONS: Reporting multiple effect estimates from a single model may lead to misinterpretation and lack of reproducibility. This example highlights the need for careful consideration of the types of effects estimated in statistical models.

Causal inference in studies of preterm babies: a simulation study.

OBJECTIVE: Using a simple simulation, we illustrate why associations estimated from studies restricted to preterm births cannot be interpreted causally. DESIGN, SETTING AND POPULATION: Data simulation involving a hypothetical cohort of fetuses who may be healthy or have one or more of four pathological factors (termed A through D, increasing in severity) with known effects on gestational length and risk of mortality. We focus on babies born at ≤32 weeks of gestation. METHODS: We visually represent the simulated population and compare the association between A (which may represent pre-eclampsia) and neonatal death. We then repeat the exercise with D (standing in for chorioamnionitis) as the exposure of interest. MAIN OUTCOME MEASURES: Odds ratios of neonatal death in the simulated data. RESULTS: In most weeks, and for both A and D, the calculated odds ratios are substantially biased and underestimate the true risk of neonatal death associated with each pathology. For example, factor A has a true causal odds ratio of 1.50, yet it appears protective among births ≤32 weeks (estimated crude odds ratio 0.39; gestational age-adjusted odds ratio 0.71). CONCLUSIONS: Among very preterm births, virtually all babies are born with pathologies that increase the risk of adverse outcomes. Hence, babies exposed to one factor (e.g. pre-eclampsia) are compared with babies who have a mix of other pathologies. Such selection bias affects studies carried out among very preterm births (e.g. where pre-eclampsia appears to reduce risk of adverse neonatal outcomes). TWEETABLE ABSTRACT: Selection bias affects studies of preterm births, complicating interpretation.

Maternal race and intergenerational preterm birth recurrence.

BACKGROUND: Preterm birth is a complex disorder with a heritable genetic component. Studies of primarily White women born preterm show that they have an increased risk of subsequently delivering preterm. This risk of intergenerational preterm birth is poorly defined among Black women. OBJECTIVE: Our objective was to evaluate and compare intergenerational preterm birth risk among non-Hispanic Black and non-Hispanic White mothers. STUDY DESIGN: This was a population-based retrospective cohort study, using the Virginia Intergenerational Linked Birth File. All non-Hispanic Black and non-Hispanic White mothers born in Virginia 1960 through 1996 who delivered their first live-born, nonanomalous, singleton infant ≥20 weeks from 2005 through 2009 were included. We assessed the overall gestational age distribution between non-Hispanic Black and White mothers born term and preterm (<37 weeks) and their infants born term and preterm (<37 weeks) using Cox regression and Kaplan-Meier survivor functions. Mothers were grouped by maternal gestational age at delivery (term, ≥37 completed weeks; late preterm birth, 34-36 weeks; and early preterm birth, <34 weeks). The primary outcomes were: (1) preterm birth among all eligible births; and (2) suspected spontaneous preterm birth among births to women with medical complications (eg, diabetes, hypertension, preeclampsia and thus higher risk for a medically indicated preterm birth). Multivariable logistic regression was used to estimate odds of preterm birth and spontaneous preterm birth by maternal race and maternal gestational age after adjusting for confounders including maternal education, maternal age, smoking, drug/alcohol use, and infant gender. RESULTS: Of 173,822 deliveries captured in the intergenerational birth cohort, 71,676 (41.2%) women met inclusion criteria for this study. Of the entire cohort, 30.0% (n = 21,467) were non-Hispanic Black and 70.0% were non-Hispanic White mothers. Compared to non-Hispanic White mothers, non-Hispanic Black mothers were more likely to have been born late preterm (6.8% vs 3.7%) or early preterm (2.8 vs 1.0%), P < .001. Non-Hispanic White mothers who were born (early or late) preterm were not at an increased risk of early or late preterm delivery compared to non-Hispanic White mothers born term. The risk of early preterm birth was most pronounced for Black mothers who were born early preterm (adjusted odds ratio, 3.26; 95% confidence interval, 1.77-6.02) compared to non-Hispanic White mothers. CONCLUSION: We found an intergenerational effect of preterm birth among non-Hispanic Black mothers but not non-Hispanic White mothers. Black mothers born <34 weeks carry the highest risk of delivering their first child very preterm. Future studies should elucidate the underlying pathways leading to this racial disparity.

Advanced paternal age and stillbirth rate: a nationwide register-based cohort study of 944,031 pregnancies in Denmark.

Advanced paternal age has been associated with a variety of rare conditions and diseases of great public health impact. An increased number of de novo point mutations in sperm with increasing age have been suggested as a mechanism, which would likely also affect fetal viability. We examined the association between paternal age and stillbirth rate in a large nationwide cohort. We identified all pregnancies in Denmark from 1994 to 2010 carried to a gestational age of at least 22 completed weeks (n = 944,031) as registered in national registers and linked to individual register data about the parents. The hazard ratio of stillbirth according to paternal age was estimated, adjusted for maternal age in 1-year categories, year of outcome, and additionally parental educational levels. The relative rate of stillbirth (n = 4946) according to paternal age was found to be J-shaped with the highest hazard ratio for fathers aged more than 40 years when paternal age was modelled using restricted cubic splines. When modelled categorically, the adjusted hazard ratios of stillbirth were as follows: <25, 1.16 (95% confidence interval, CI 1.01-1.34); 25-29, 1.03 (95% CI 0.95-1.11); 35-39, 1.16 (95% CI 1.07-1.26); 40-44, 1.41 (95% CI 1.26-1.59); 45-49, 1.20 (95% CI 0.97-1.49); 50+, 1.58 (95% CI 1.18-2.11), compared with fathers aged 30-34 years. These estimates attenuated slightly when further adjusted for parental education. Our study showed that paternal age was associated with the relative rate of stillbirth in a J-shaped manner with the highest hazard ratios among fathers aged more than 40 years.

Relationship Between Mean Leucocyte Telomere Length and Measures of Allostatic Load in US Reproductive-Aged Women, NHANES 1999-2002.

BACKGROUND: Reproductive health disparities may be partly explained by the cumulative effects of chronic stress experienced by socially disadvantaged groups. Although, telomere length (TL) and allostatic load score have each been used as biological markers of stress, the relationship between these two measures is unknown. METHODS: We investigated the association between leucocyte TL and allostatic load score in 1503 non-pregnant women (20-44 years) participating in the National Health and Nutrition Examination Survey, 1999-2002. We constructed six different allostatic load scores using either quartile- or clinical-based cut-points for 14 biomarkers based on previously published methods. We estimated associations between TL and allostatic load scores and component biomarkers using linear regression, also assessing interactions by race/ethnicity. RESULTS: After adjustment for age, longer TL was associated with higher HDL cholesterol and lower C-reactive protein and creatinine clearance; TL was not associated with the other component biomarkers. Shorter TL was associated with higher allostatic load scores for the two clinical cut-point-based scores after adjustment for age, but not the four scores based on quartile cut-points. Significant interactions by race/ethnicity were observed for TL and HbA1c and triglycerides, but not for other component biomarkers or allostatic load scores. CONCLUSIONS: Although TL and allostatic load score are both considered measures of cumulative stress, most component biomarkers and scores using quartile-based cut-points were not associated with TL. In reproductive-aged women, allostatic load scores using clinical-based cut-points were more strongly associated with TL compared with quartile-based scores.

Constructing Causal Diagrams for Common Perinatal Outcomes: Benefits, Limitations and Motivating Examples with Maternal Antidepressant Use in Pregnancy.

BACKGROUND: Covariate selection to reduce bias in observational data analysis has primarily relied upon statistical criteria to guide researchers. This approach may lead researchers to condition on variables that ultimately increase bias in the effect estimates. The use of directed acyclic graphs (DAGs) aids researchers in constructing thoughtful models based on hypothesised biologic mechanisms to produce the least biased effect estimates possible. METHODS: After providing an overview of different relations in DAGs and the prevailing mechanisms by which conditioning on variables increases or reduces bias in a model, we illustrate examples of DAGs for maternal antidepressants in pregnancy and four separate perinatal outcomes. RESULTS: By comparing and contrasting the diagrams for maternal antidepressant use in pregnancy and spontaneous abortion, major malformations, preterm birth, and postnatal growth, we illustrate the different conditioning sets required for each model. Moreover, we illustrate why it is not appropriate to condition on the same set of covariates for the same exposure and different perinatal outcomes. We further discuss potential selection biases, overadjustment of mediators on the causal path, and sufficient sets of conditioning variables. CONCLUSION: In our efforts to construct parsimonious models that minimise confounding and selection biases, we must rely upon our scientific knowledge of the causal mechanism. By structuring data collection and analysis around hypothesised DAGs, we ultimately aim to validly estimate the causal effect of interest.

Postpartum psychiatric emergency visits: a nested case-control study.

Mental health conditions are one of the most common reasons for postpartum emergency department (ED) visits. Characteristics of women using the ED and their mental health service use before presentation are unknown. We characterized all women in Ontario, Canada (2006-2012), who delivered a live born infant and had a psychiatric ED visit within 1 year postpartum (n = 8728). We compared those whose ED visit was the first physician mental health contact since delivery to those who had accessed mental health services on specific indicators of marginalization hypothesized to be associated with lower likelihood of mental health contact prior to the ED visit. For 60.4 % of women, this was the first physician mental health contact since delivery. The majority were presenting with a mood or anxiety disorder, and only 13.6 % required hospital admission. These women were more likely to have material deprivation and residential instability than women with contact (Q5 vs. Q1 aORs 1.30, 95 % CI 1.12-1.50; 1.17, 95 % CI 1.01-1.36), to live in rural vs. urban areas (aOR 1.58, 95 % CI 1.38-1.80), and to be low vs. high income quintile (aOR 1.18, 95 % CI 1.01-1.38). The frequent use of ED services as the first point of contact for mental health concerns suggests that interventions to improve timely and equitable access to effective outpatient postpartum mental health care are needed. Marginalized women are at particularly high risk of not having accessed outpatient services prior to an ED visit, and therefore, future research and interventions will specifically need to consider the needs of this group.

Recognizing Excellence in Maternal and Child Health (MCH) Epidemiology: The 2014 National MCH Epidemiology Awards.

PURPOSE: The impact of programs, policies, and practices developed by professionals in the field of maternal and child health (MCH) epidemiology is highlighted biennially by 16 national MCH agencies and organizations, or the Coalition for Excellence in MCH Epidemiology. DESCRIPTION: In September 2014, multiple leading agencies in the field of MCH partnered to host the national CityMatCH Leadership and MCH Epidemiology Conference in Phoenix, Arizona. The conference offered opportunities for peer exchange; presentation of new scientific methodologies, programs, and policies; dialogue on changes in the MCH field; and discussion of emerging MCH issues relevant to the work of local, state, and national MCH professionals. During the conference, the National MCH Epidemiology Awards were presented to individuals, teams, institutions, and leaders for significantly contributing to the improved health of women, children, and families. ASSESSMENT: During the conference, the Coalition presented seven deserving health researchers and research groups with national awards in the areas of advancing knowledge, effective practice, outstanding leadership, young professional achievement, and lifetime achievement. The article highlights the accomplishments of these national-level awardees. CONCLUSION: Recognition of deserving professionals strengthens the field of MCH epidemiology, and sets the standard for exceptional research, mentoring, and practice.

Epidemiology's continuing contribution to public health: The power of "Then and Now".

The 47th annual meeting of the Society for Epidemiologic Research hosted 17 invited speakers charged by the Executive Committee with presenting some of the many ways that epidemiologists have improved the health of the general population. There were 9 "Then and Now" sessions that were structured to focus on how early epidemiologists overcame research hurdles and advanced health through innovative strategies. For most topics, a longstanding expert was paired with an excellent contemporary epidemiologist working in the area, and both were given the freedom to deliver an integrated story about epidemiology's temporal role in protecting and promoting public health. Epidemiologic discoveries in cardiovascular, cancer, and perinatal epidemiology were discussed on day 1, followed by discussions of accomplishments in reducing exposures that adversely impact health (nutrition, environment/occupation, and tobacco use) on day 2. Topics with relevancy for many aspects of epidemiology were presented on day 3, including infectious diseases, social forces, and causal thinking in epidemiologic research. Given the large number of outstanding senior and junior epidemiologists that attended the meeting, choosing speakers was a unique challenge. What became evident from all sessions was the passion that epidemiologists have for population health, tempered with concerns for remaining true to epidemiologic principles, the timely adoption of innovative methods, and the responsible interpretation of research findings.

Advanced Paternal Age and Risk of Musculoskeletal Congenital Anomalies in Offspring.

OBJECTIVE: Previous research suggests that advanced paternal age increases the risk of musculoskeletal congenital anomalies (CAs) in offspring, but findings are inconsistent. This study aims to investigate the risk of musculoskeletal CAs according to paternal age at birth in an unselected population covering cohort of children. STUDY DESIGN: A register-based prospective study of 1,605,885 children born in Denmark, 1978-2004, using information from record-linked health and administrative registers. The association between paternal age and overall musculoskeletal CAs, limb anomalies, craniosynostosis, skeletal dysplasias, syndromic musculoskeletal CAs, and other musculoskeletal CAs were investigated by multiple logistic regression analysis. RESULTS: For overall musculoskeletal CAs, a slightly higher risk per 10-year increase in paternal age was found (odds ratio [OR] = 1.06 [95% CI: 1.01-1.11; where CI is confidence interval]). A 26% (95% CI: 2-56%) excess risk was found for fathers aged 50+ years compared to fathers aged 30-34 years. For syndromic musculoskeletal CAs, excess risks were found for fathers aged 40+ years, compared to fathers aged 30-34 years (40-44: OR = 1.38 [95% CI: 1.01-1.88], 45-49: OR = 1.45 [95% CI: 0.89-2.34], 50+: OR = 1.42 [95% CI: 0.73-2.79]). The risks in all other subgroups of musculoskeletal CAs were increased for fathers aged 50+ years. CONCLUSIONS: A slightly higher risk for overall musculoskeletal CAs in offspring was found with increasing paternal age, mainly due to an excess risk of syndromic musculoskeletal CAs for fathers aged 40+ years. While associations between paternal age 50+ years and increased risk of all subtypes of musculoskeletal CAs were indicated, advanced paternal age likely plays a minor role in the etiology of these anomalies.

Stochastic mediation contrasts in epidemiologic research: interpregnancy interval and the educational disparity in preterm delivery.

Low maternal education is consistently associated with increased risk of preterm delivery (PTD). The interpregnancy interval (IPI), defined as the time between the date of a previous birth and the conception date of the index pregnancy, may mediate this relationship. We estimated controlled direct effects to assess whether hypothetical interventions designed to increase IPIs would reduce the educational disparity in PTD. We introduce a technique for estimating controlled direct effects under interventions that set only some persons in the population to a specific mediator value. We used data from 847,618 singleton livebirths occurring in Quebec, Canada, between 1989 and 2010. Compared with mothers with some university education (≥14 years), mothers with less than high school (<11 years), high school (11 years), and some college (12-13 years) had excess PTD risks of 2.6% (95% confidence interval (CI): 2.4, 2.8), 1.5% (95% CI: 1.4, 1.7), and 1.0% (95% CI: 0.9, 1.1), respectively. Risk differences under an intervention corresponding to the Healthy People 2020 objective of reducing the number of mothers with IPIs less than 18 months by 3% were no different from those for the total relationship. Our results suggest that interventions designed to increase the length of short IPIs will yield no important change in the PTD disparity by maternal educational level.