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1.  Development of the Migrant Friendly Maternity Care Questionnaire (MFMCQ) for migrants to Western societies: an international Delphi consensus process 
Background
Through the World Health Assembly Resolution, ‘Health of Migrants’, the international community has identified migrant health as a priority. Recommendations for general hospital care for international migrants in receiving-countries have been put forward by the Migrant Friendly Hospital Initiative; adaptations of these recommendations specific to maternity care have yet to be elucidated and validated. We aimed to develop a questionnaire measuring migrant-friendly maternity care (MFMC) which could be used in a range of maternity care settings and countries.
Methods
This study was conducted in four stages. First, questions related to migrant friendly maternity care were identified from existing questionnaires including the Migrant Friendliness Quality Questionnaire, developed in Europe to capture recommended general hospital care for migrants, and the Mothers In a New Country (MINC) Questionnaire, developed in Australia and revised for use in Canada to capture the maternity care experiences of migrant women, and combined to create an initial MFMC questionnaire. Second, a Delphi consensus process in three rounds with a panel of 89 experts in perinatal health and migration from 17 countries was undertaken to identify priority themes and questions as well as to clarify wording and format. Third, the draft questionnaire was translated from English to French and Spanish and back-translated and subsequently culturally validated (assessed for cultural appropriateness) by migrant women. Fourth, the questionnaire was piloted with migrant women who had recently given birth in Montreal, Canada.
Results
A 112-item questionnaire on maternity care from pregnancy, through labour and birth, to postpartum care, and including items on maternal socio-demographic, migration and obstetrical characteristics, and perceptions of care, has been created - the Migrant Friendly Maternity Care Questionnaire (MFMCQ) – in three languages (English, French and Spanish). It is completed in 45 minutes via interview administration several months post-birth.
Conclusions
A 4-stage process of questionnaire development with international experts in migrant reproductive health and research resulted in the MFMCQ, a questionnaire measuring key aspects of migrant-sensitive maternity care. The MFMCQ is available for further translation and use to examine and compare care and perceptions of care within and across countries, and by key socio-demographic, migration, and obstetrical characteristics of migrant women.
doi:10.1186/1471-2393-14-200
PMCID: PMC4088918  PMID: 24916892
Childbirth; Ethnicity; Immigration and emigration; Maternal-child health services; Patient-centred care; Patient satisfaction; Pregnancy; Quality of health care; Questionnaires; Women
2.  Quality of prenatal care questionnaire: instrument development and testing 
Background
Utilization indices exist to measure quantity of prenatal care, but currently there is no published instrument to assess quality of prenatal care. The purpose of this study was to develop and test a new instrument, the Quality of Prenatal Care Questionnaire (QPCQ).
Methods
Data for this instrument development study were collected in five Canadian cities. Items for the QPCQ were generated through interviews with 40 pregnant women and 40 health care providers and a review of prenatal care guidelines, followed by assessment of content validity and rating of importance of items. The preliminary 100-item QPCQ was administered to 422 postpartum women to conduct item reduction using exploratory factor analysis. The final 46-item version of the QPCQ was then administered to another 422 postpartum women to establish its construct validity, and internal consistency and test-retest reliability.
Results
Exploratory factor analysis reduced the QPCQ to 46 items, factored into 6 subscales, which subsequently were validated by confirmatory factor analysis. Construct validity was also demonstrated using a hypothesis testing approach; there was a significant positive association between women’s ratings of the quality of prenatal care and their satisfaction with care (r = 0.81). Convergent validity was demonstrated by a significant positive correlation (r = 0.63) between the “Support and Respect” subscale of the QPCQ and the “Respectfulness/Emotional Support” subscale of the Prenatal Interpersonal Processes of Care instrument. The overall QPCQ had acceptable internal consistency reliability (Cronbach’s alpha = 0.96), as did each of the subscales. The test-retest reliability result (Intra-class correlation coefficient = 0.88) indicated stability of the instrument on repeat administration approximately one week later. Temporal stability testing confirmed that women’s ratings of their quality of prenatal care did not change as a result of giving birth or between the early postpartum period and 4 to 6 weeks postpartum.
Conclusion
The QPCQ is a valid and reliable instrument that will be useful in future research as an outcome measure to compare quality of care across geographic regions, populations, and service delivery models, and to assess the relationship between quality of care and maternal and infant health outcomes.
doi:10.1186/1471-2393-14-188
PMCID: PMC4074335  PMID: 24894497
Prenatal care; Quality of care; Measurement; Instrument; Reliability; Validity; Psychometric testing
3.  Contribution of prepregnancy body mass index and gestational weight gain to caesarean birth in Canada 
Background
Overweight and obese women are known to be at increased risk of caesarean birth. This study estimates the contribution of prepregnancy body mass index (BMI) and gestational weight gain (GWG) to caesarean births in Canada.
Methods
We analyzed data from women in the Canadian Maternity Experiences Survey who had a singleton term live birth in 2005-2006. Adjusted odds ratios for caesarean birth across BMI and GWG groups were derived, separately for nulliparous women and parous women with and without a prior caesarean. Population attributable fractions of caesarean births associated with above normal BMI and excess GWG were calculated.
Results
The overall caesarean birth rate was 25.7%. Among nulliparous and parous women without a previous caesarean birth, rates in obese women were 45.1% and 9.7% respectively, and rates in women who gained above their recommended GWG were 33.5% and 8.0% respectively. Caesarean birth was more strongly associated with BMI than with GWG. However, due to the high prevalence of excess GWG (48.8%), the proportion of caesareans associated with above normal BMI and excess GWG was similar [10.1% (95% CI: 9.9-10.2) and 10.9% (95% CI: 10.7-11.1) respectively]. Overall, one in five (20.2%, 95% CI: 20.0-20.4) caesarean births was associated with above normal BMI or excess GWG.
Conclusions
Overweight and obese BMI and above recommended GWG are significantly associated with caesarean birth in singleton term pregnancies in Canada. Strategies to reduce caesarean births must include measures to prevent overweight and obese BMI prior to conception and promote recommended weight gain throughout pregnancy.
doi:10.1186/1471-2393-14-106
PMCID: PMC3995143  PMID: 24641703
Population attributable fractions; Maternal weight; Caesarean section
4.  Study protocol for a randomized, controlled, superiority trial comparing the clinical and cost- effectiveness of integrated online mental health assessment-referral-care in pregnancy to usual prenatal care on prenatal and postnatal mental health and infant health and development: the Integrated Maternal Psychosocial Assessment to Care Trial (IMPACT) 
Trials  2014;15:72.
Background
Stress, depression, and anxiety affect 15 to 25% of pregnant women. However, fewer than 20% of prenatal care providers assess and treat mental health problems and fewer than 20% of pregnant women seek mental healthcare. For those who seek treatment, the lack of health system integration and existing barriers frequently prevent treatment access. Without treatment, poor prenatal mental health can persist for years and impact future maternal, child, and family well-being.
Methods/Design
The purpose of this randomized controlled trial is to evaluate the effectiveness of an integrated process of online psychosocial assessment, referral, and cognitive behavior therapy (CBT) for pregnant women compared to usual prenatal care (no formal screening or specialized care). The primary outcome is self-reported prenatal depression, anxiety, and stress symptoms at 6 to 8 weeks postrandomization. Secondary outcomes are postpartum depression, anxiety, and stress symptoms; self-efficacy; mastery; self-esteem; sleep; relationship quality; coping; resilience; Apgar score; gestational age; birth weight; maternal-infant attachment; infant behavior and development; parenting stress/competence; and intervention cost-effectiveness, efficiency, feasibility, and acceptability. Pregnant women are eligible if they: 1) are <28 weeks gestation; 2) speak/read English; 3) are willing to complete email questionnaires; 4) have no, low, or moderate psychosocial risk on screening at recruitment; and 5) are eligible for CBT. A sample of 816 women will be recruited from large, urban primary care clinics and allocation is by computer-generated randomization. Women in the intervention group will complete an online psychosocial assessment, and those with mild or moderate depression, anxiety, or stress symptoms then complete six interactive cognitive behavior therapy modules. All women will complete email questionnaires at 6 to 8 weeks postrandomization and at 3, 6, and 12 months postpartum. Clinic-based providers and researchers conducting chart abstraction and analysis are blinded. Qualitative interviews with 8 to 10 healthcare providers and 15 to 30 intervention group women will provide data on feasibility and acceptability of the intervention. Results of this trial will determine the feasibility and effectiveness of an integrated approach to prenatal mental healthcare and the use of highly accessible computer-based psychosocial assessment and CBT on maternal, infant, and family-based outcomes.
Trial registration
ClinicalTrials.gov Identifier: NCT01901796
doi:10.1186/1745-6215-15-72
PMCID: PMC4015853  PMID: 24597683
psychosocial assessment; online; screening; cognitive behavior therapy; pregnancy; depression; anxiety; stress; randomized controlled trial
5.  Birth outcomes and infant mortality among First Nations Inuit, and non-Indigenous women by northern versus southern residence, Quebec 
Background
In circumpolar countries such as Canada, northern regions represent a unique geographical entity climatically, socioeconomically and environmentally. There is a lack of comparative data on birth outcomes among Indigenous and non-Indigenous subpopulations within northern regions and compared with southern regions.
Methods
A cohort study of all births by maternal mother tongue to residents of northern (2616 First Nations (North American Indians), 2388 Inuit and 5006 non-Indigenous) and southern (2563 First Nations, 810 643 non-Indigenous) Quebec, 1991–2000.
Results
Compared with births to southern non-Indigenous mother tongue women, births to northern women of all three mother tongue groups were at substantially elevated risks of infant death (adjusted OR (aOR) 1.7–2.9), especially postneonatal death (aOR 2.2–4.4) after controlling for maternal education, age, marital status and parity. The risk elevation in perinatal death was greater for southern First Nations (aOR 1.6) than for northern First Nations (aOR 1.2). Infant macrosomia was highly prevalent among First Nations in Quebec, especially in the north (31% vs 24% in the south). Within northern regions, Inuit births were at highest risk of preterm delivery (aOR 1.4) and infant death (aOR 1.6).
Conclusion
All northern infants (First Nations, Inuit or non-Indigenous) were at substantially elevated risk of infant death in Quebec, despite a universal health insurance system. Southern First Nations newborns have not benefited from the more advanced perinatal care facilities in southern regions. Environmental influences may partly account for the very high prevalence of macrosomia among First Nations in northern Quebec.
doi:10.1136/jech.2009.092619
PMCID: PMC3133748  PMID: 21051777 CAMSID: cams1702
6.  Advanced maternal age and risk perception: A qualitative study 
Background
Advanced maternal age (AMA) is associated with several adverse pregnancy outcomes, hence these pregnancies are considered to be “high risk.” A review of the empirical literature suggests that it is not clear how women of AMA evaluate their pregnancy risk. This study aimed to address this gap by exploring the risk perception of pregnant women of AMA.
Methods
A qualitative descriptive study was undertaken to obtain a rich and detailed source of explanatory data regarding perceived pregnancy risk of 15 women of AMA. The sample was recruited from a variety of settings in Winnipeg, Canada. In-depth interviews were conducted with nulliparous women aged 35 years or older, in their third trimester, and with singleton pregnancies. Interviews were recorded and transcribed verbatim, and content analysis was used to identify themes and categories.
Results
Four main themes emerged: definition of pregnancy risk, factors influencing risk perception, risk alleviation strategies, and risk communication with health professionals.
Conclusions
Several factors may influence women's perception of pregnancy risk including medical risk, psychological elements, characteristics of the risk, stage of pregnancy, and health care provider’s opinion. Understanding these influential factors may help health professionals who care for pregnant women of AMA to gain insight into their perspectives on pregnancy risk and improve the effectiveness of risk communication strategies with this group.
doi:10.1186/1471-2393-12-100
PMCID: PMC3490979  PMID: 22988825
Advanced maternal age; Risk perception; Qualitative study
7.  North-South Gradients in Adverse Birth Outcomes for First Nations and Others in Manitoba, Canada 
Objective
to determine the relationship of north-south place of residence to adverse birth outcomes among First Nations and non-First Nations in Manitoba, Canada, a setting with universal health insurance.
Study Design
Live birth records (n=151,472) for the province of Manitoba, Canada 1991–2000 were analyzed, including 25,743 First Nations and 125,729 non-First Nations infants. North-south and rural-urban residence was determined for each birth through geocoding.
Results
Comparing First Nations to non-First Nations, crude rates in North (and South) were: 7.0% versus 8.4% (9.3% versus 7.5%) for preterm birth; 6.1% versus 8.4% (8.7% versus 10.0%) for small-for-gestational-age birth, 4.2% versus 6.5% (6.2% versus 5.7%) for low birth weight, and 20.6% versus 13.7% (17.0% versus 11.0%) for large-for-gestational-age birth; and mortality per 1000 - neonatal 3.2 versus 6.2 (3.8 versus 3.3), post-neonatal 6.4 versus 6.4 (5.8 versus 1.5), and infant 9.5 versus 12.6 (9.6 versus 4.8). Adjusting for observed maternal and infant characteristics and rural versus urban residence, the North was high risk for large-for-gestational-age birth for both First Nations and non-First Nations. First Nations’ risk of preterm, small-for-gestational-age and low birth weight was lowest in the North, but for non-First Nations, the North was lower only for small-for-gestational-age. First Nations mortality indicators were similar North to South, but for non-First Nations, the North was high risk.
Conclusion
North-South place of residence does matter for adverse birth outcomes, but the effects may differ by ethnicity and could require different intervention strategies.
PMCID: PMC3329440  PMID: 22523523 CAMSID: cams2159
North-south residence; First Nations; preterm birth; fetal growth; infant mortality; Aboriginal; North American Indian
8.  Women's and care providers' perspectives of quality prenatal care: a qualitative descriptive study 
Background
Much attention has been given to the adequacy of prenatal care use in promoting healthy outcomes for women and their infants. Adequacy of use takes into account the timing of initiation of prenatal care and the number of visits. However, there is emerging evidence that the quality of prenatal care may be more important than adequacy of use. The purpose of our study was to explore women's and care providers' perspectives of quality prenatal care to inform the development of items for a new instrument, the Quality of Prenatal Care Questionnaire. We report on the derivation of themes resulting from this first step of questionnaire development.
Methods
A qualitative descriptive approach was used. Semi-structured interviews were conducted with 40 pregnant women and 40 prenatal care providers recruited from five urban centres across Canada. Data were analyzed using inductive open and then pattern coding. The final step of analysis used a deductive approach to assign the emergent themes to broader categories reflective of the study's conceptual framework.
Results
The three main categories informed by Donabedian's model of quality health care were structure of care, clinical care processes, and interpersonal care processes. Structure of care themes included access, physical setting, and staff and care provider characteristics. Themes under clinical care processes were health promotion and illness prevention, screening and assessment, information sharing, continuity of care, non-medicalization of pregnancy, and women-centredness. Interpersonal care processes themes were respectful attitude, emotional support, approachable interaction style, and taking time. A recurrent theme woven throughout the data reflected the importance of a meaningful relationship between a woman and her prenatal care provider that was characterized by trust.
Conclusions
While certain aspects of structure of care were identified as being key dimensions of quality prenatal care, clinical and interpersonal care processes emerged as being most essential to quality care. These processes are important as they have a role in mitigating adverse outcomes, promoting involvement of women in their own care, and keeping women engaged in care. The findings suggest key considerations for the planning, delivery, and evaluation of prenatal care. Most notably, care should be woman-centred and embrace shared decision making as an essential element.
doi:10.1186/1471-2393-12-29
PMCID: PMC3352181  PMID: 22502640
9.  Neighborhood Socioeconomic Characteristics, Birth Outcomes and Infant Mortality among First Nations and Non-First Nations in Manitoba, Canada 
Objective
Little is known about the possible impacts of neighborhood socioeconomic status on birth outcomes and infant mortality among Aboriginal populations. We assessed birth outcomes and infant mortality by neighborhood socioeconomic status among First Nations and non-First Nations in Manitoba.
Study Design
We conducted a retrospective birth cohort study of all live births (26,176 First Nations, 129,623 non-First Nations) to Manitoba residents, 1991–2000. Maternal residential postal codes were used to assign four measures of neighborhood socioeconomic status (concerning income, education, unemployment, and lone parenthood) obtained from 1996 census data.
Results
First Nations women were much more likely to live in neighborhoods of low socioeconomic status. First Nations infants were much more likely to die during their first year of life [risk ratio (RR) =1.9] especially during the postneonatal period (RR=3.6). For both First Nations and non-First Nations, living in neighborhoods of low socioeconomic status was associated with an increased risk of infant death, especially postneonatal death. For non-First Nations, higher rates of pre-term and small-for-gestational-age birth were consistently observed in low socioeconomic status neighborhoods, but for First Nations the associations were less consistent across the four measures of socioeconomic status. Adjusting for neighborhood socioeconomic status, the disparities in infant and postneonatal mortality between First Nations and non-First Nations were attenuated.
Conclusion
Low neighborhood socioeconomic status was associated with an elevated risk of infant death even among First Nations, and may partly account for their higher rates of infant mortality compared to non-First Nations in Manitoba.
PMCID: PMC3266303  PMID: 22287997 CAMSID: cams1725
Aboriginal health; first nations; neighborhood socioeconomic status; birth outcome; infant mortality
10.  Urban Living is Not Associated with Better Birth and Infant Outcomes among Inuit and First Nations in Quebec 
Objective
There is limited and inconsistent evidence concerning rural versus urban differences in birth and infant outcomes for Indigenous peoples. We assessed birth and infant outcomes among Inuit, First Nations and French mother tongue groups by rural versus urban residence in Quebec, Canada.
Study Deign
A retrospective birth cohort study of 5,184 First Nations, 2,527 Inuit and 652,940 French mother tongue (the majority reference) births in Quebec, 1991–2000.
Results
In general, rural living was associated with slightly less favorable birth outcomes for French mother tongue women, but somewhat better outcomes for Indigenous women. For both Inuit and First Nations, rural births were half as likely to be small-for-gestational-age compared to urban births. Among First Nations, the difference in infant mortality rates comparing urban to rural areas was not statistically significant. Compared to infants of French mother tongue women, Inuit and First Nations infants were much less likely to be small-for-gestational-age in rural areas, while such an “advantage” diminished for First Nations and reversed for Inuit in urban areas. The disparities in infant mortality among First Nations versus French mother tongue births were greater in urban than in rural areas. These patterns of results remained after adjusting for maternal characteristics.
Conclusion
Living in urban areas was not associated with better birth and infant outcomes for Inuit and First Nations in Quebec despite universal health insurance coverage, strongly indicating a need for improved socioeconomic conditions, perinatal and infant care for Indigenous people living in urban areas.
PMCID: PMC3266304  PMID: 22287996 CAMSID: cams1726
Indigenous health; infant mortality; fetal growth restriction; rural; urban
11.  Community Remoteness, Perinatal Outcomes and Infant Mortality among First Nations in Quebec 
Objective
Little is known about community remoteness in relation to birth outcomes among Indigenous populations. We assessed whether community remoteness matters for perinatal outcomes and infant mortality in Quebec First Nations communities.
Study Design
A retrospective cohort study of all births (n=11,033) to residents of First Nations communities in Quebec 1991–2000, using linked vital statistics data. First Nations communities were grouped by community remoteness into four zones from the least to most remote.
Results
Preterm birth rates declined progressively from the least remote (8.0%) to the most remote (5.7%) zones (p=0.002). In contrast, total fetal and infant mortality rose progressively from the least remote (10.4 per 1000) to the most remote (22.7 per 1000) zones (p<0.001). The excess infant mortality in the more remote zones was mainly due to higher rates of postneonatal mortality. Similar patterns were observed after adjusting for maternal age, education, parity and marital status. Substantially elevated risks in most remote communities remained for perinatal death (adjusted OR=2.1), postneonatal death (adjusted OR=2.7), and total fetal and infant death (adjusted OR=2.3).
Conclusion
Living in more remote First Nations communities was associated with a substantially higher risk of fetal and infant death, especially postneonatal death, despite a lower risk of preterm delivery. There is a need for more effective perinatal and infant care programs in more remote First Nations communities to reduce perinatal and infant mortality.
PMCID: PMC3265536  PMID: 22282717 CAMSID: cams1727
Community remoteness; first nations; preterm birth; perinatal mortality; infant mortality
12.  Individual- and Community-Level Disparities in Birth Outcomes and Infant Mortality among First Nations, Inuit and Other Populations in Quebec 
Objective
We assessed individual- and community-level disparities and trends in birth outcomes and infant mortality among First Nations (North American Indians) and Inuit versus other populations in Quebec, Canada.
Methods
A retrospective birth cohort study of all births to Quebec residents, 1991–2000. At the individual level, we examined outcomes comparing births to First Nations and Inuit versus other mother tongue women. At the community level, we compared outcomes among First Nations and Inuit communities versus other communities.
Results
First Nations and Inuit births were much less likely to be small-for-gestational-age but much more likely to be large-for-gestational-age compared to other births at the individual or community level, especially for First Nations. At both levels, Inuit births were 1.5 times as likely to be preterm. At the individual level, total fetal and infant mortality rates were 2 times as high for First Nations, and 3 times as high for Inuit. Infant mortality rates were 2 times as high for First Nations, and 4 times as high for Inuit. There were no reductions in these disparities between 1991–1995 and 1996–2000. Modestly smaller disparities in total fetal and infant mortality were observed for First Nations at the community level (risk ratio=1.6), but for Inuit there were similar disparities at both levels. These disparities remained substantial after adjusting for maternal characteristics.
Conclusion
There were large and persistent disparities in fetal and infant mortality among First Nations and Inuit versus other populations in Quebec based on individual- or community-level assessments, indicating a need to improve socioeconomic conditions as well as perinatal and infant care for Aboriginal peoples.
PMCID: PMC3265542  PMID: 22282716 CAMSID: cams1728
Health disparities; aboriginal people; preterm birth; fetal growth; fetal and infant mortality
13.  Experiences of violence before and during pregnancy and adverse pregnancy outcomes: An analysis of the Canadian Maternity Experiences Survey 
Background
Abuse and violence against women constitute a global public health problem and are particularly important among women of reproductive age. The literature is not conclusive regarding the impact of violence against pregnant women on adverse pregnancy outcomes, such as preterm birth, small for gestational age and postpartum depression. Most studies have been conducted on relatively small samples of high-risk women. Our objective was to investigate what dimensions of violence against pregnant women were associated with preterm birth, small for gestational age and postpartum depression in a nationally representative sample of Canadian women.
Methods
We analysed data of the Maternity Experiences Survey, a nationally representative survey of Canadian women giving birth in 2006. The comprehensive questionnaire included a 19-item section to collect information on different dimensions of abuse and violence, such as type, frequency, timing and perpetrator of violence. The survey design is a stratified simple random sample from the 2006 Canadian Census sampling frame. Participants were 6,421 biological mothers (78% response rate) 15 years and older who gave birth to a singleton live birth and lived with their infant at the time of the survey. Logistic regression was used to compute Odds Ratios. Survey weights were used to obtain point estimates and 95% confidence intervals were obtained with the jacknife method of variance estimation. Covariate control was informed by use of directed acyclic graphs.
Results
No statistically significant associations were found for preterm birth or small for gestational age, after adjustment. Most dimensions of violence were associated with postpartum depression, particularly the combination of threats and physical violence starting before and continuing during pregnancy (Adjusted Odds Ratio = 4.1, 95% confidence interval: 1.9, 8.9) and perpetrated by the partner (4.3: 2.1, 8.7).
Conclusions
Our findings provide weak evidence of an association between experiences of abuse before and during pregnancy and preterm birth and small for gestational age but they indicate that several dimensions of abuse and violence are consistently associated with postpartum depression.
doi:10.1186/1471-2393-11-42
PMCID: PMC3141595  PMID: 21649909
14.  Birth Outcomes and Infant Mortality by the Degree of Rural Isolation Among First Nations and Non-First Nations in Manitoba, Canada 
Context
It is unknown whether rural isolation may affect birth outcomes and infant mortality differentially for Indigenous versus non-Indigenous populations. We assessed birth outcomes and infant mortality by the degree of rural isolation among First Nations (North American Indians) and non-First Nations populations in Manitoba, Canada, a setting with universal health insurance.
Methods
A geocoding-based birth cohort study of 25,143 First Nations and 125,729 non-First Nations live births to Manitoban residents, 1991–2000. Degree of rural isolation was defined by an indicator of urban influence (no, weak, moderate/strong) based on the percentage of the workforce commuting to urban areas.
Findings
Preterm birth and low birth weight rates were somewhat lower in all rural areas regardless of the degree of isolation as compared to urban areas for both First Nations and non-First Nations. Infant mortality rates were not significantly different across areas for First Nations (10.7, 9.9, 7.9, and 9.7 per 1,000 in rural areas with no, weak, moderate/strong urban influence, and urban areas, respectively), but rates were significantly lower in less isolated areas for non-First Nations (7.4, 6.0, 5.6, and 4.6 per 1,000, respectively). Adjusted odds ratios showed similar patterns.
Conclusions
Living in less isolated areas was associated with lower infant mortality only among non-First Nations. First Nations infants do not seem to have similarly benefited from the better health care facilities in urban centers, suggesting a need to improve urban First Nations’ infant care in meeting the challenges of increasing urban migration.
doi:10.1111/j.1748-0361.2010.00279.x
PMCID: PMC3035640  PMID: 20447004 CAMSID: cams1530
birth outcomes; infant mortality; North American Indians; rural and urban; rural isolation
15.  International migration and adverse birth outcomes: role of ethnicity, region of origin and destination 
Background
The literature on international migration and birth outcomes shows mixed results. This study examined whether low birth weight (LBW) and preterm birth differed between non-migrants and migrant subgroups, defined by race/ethnicity and world region of origin and destination.
Methods
A systematic review and meta-regression analyses were conducted using three-level logistic models to account for the heterogeneity between studies and between subgroups within studies.
Results
Twenty-four studies, involving more than 30 million singleton births, met the inclusion criteria. Compared with US-born black women, black migrant women were at lower odds of delivering LBW and preterm birth babies. Hispanic migrants also exhibited lower odds for these outcomes, but Asian and white migrants did not. Sub-Saharan African and Latin-American and Caribbean women were at higher odds of delivering LBW babies in Europe but not in the USA and south-central Asians were at higher odds in both continents, compared with the native-born populations.
Conclusions
The association between migration and adverse birth outcomes varies by migrant subgroup and it is sensitive to the definition of the migrant and reference groups.
doi:10.1136/jech.2008.083535
PMCID: PMC2922721  PMID: 19692737
ethnicity; low birth weight; meta-analysis ME; migration and health; multilevel modelling; perinatal CG; preterm birth
16.  Inadequate prenatal care and its association with adverse pregnancy outcomes: A comparison of indices 
Background
The objectives of this study were to determine rates of prenatal care utilization in Winnipeg, Manitoba, Canada from 1991 to 2000; to compare two indices of prenatal care utilization in identifying the proportion of the population receiving inadequate prenatal care; to determine the association between inadequate prenatal care and adverse pregnancy outcomes (preterm birth, low birth weight [LBW], and small-for-gestational age [SGA]), using each of the indices; and, to assess whether or not, and to what extent, gestational age modifies this association.
Methods
We conducted a population-based study of women having a hospital-based singleton live birth from 1991 to 2000 (N = 80,989). Data sources consisted of a linked mother-baby database and a physician claims file maintained by Manitoba Health. Rates of inadequate prenatal care were calculated using two indices, the R-GINDEX and the APNCU. Logistic regression analysis was used to determine the association between inadequate prenatal care and adverse pregnancy outcomes. Stratified analysis was then used to determine whether the association between inadequate prenatal care and LBW or SGA differed by gestational age.
Results
Rates of inadequate/no prenatal care ranged from 8.3% using APNCU to 8.9% using R-GINDEX. The association between inadequate prenatal care and preterm birth and LBW varied depending on the index used, with adjusted odds ratios (AOR) ranging from 1.0 to 1.3. In contrast, both indices revealed the same strength of association of inadequate prenatal care with SGA (AOR 1.4). Both indices demonstrated heterogeneity (non-uniformity) across gestational age strata, indicating the presence of effect modification by gestational age.
Conclusion
Selection of a prenatal care utilization index requires careful consideration of its methodological underpinnings and limitations. The two indices compared in this study revealed different patterns of utilization of prenatal care, and should not be used interchangeably. Use of these indices to study the association between utilization of prenatal care and pregnancy outcomes affected by the duration of pregnancy should be approached cautiously.
doi:10.1186/1471-2393-8-15
PMCID: PMC2386440  PMID: 18452623
17.  Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term 
Background
The rate of elective primary cesarean delivery continues to rise, owing in part to the widespread perception that the procedure is of little or no risk to healthy women.
Methods
Using the Canadian Institute for Health Information's Discharge Abstract Database, we carried out a retrospective population-based cohort study of all women in Canada (excluding Quebec and Manitoba) who delivered from April 1991 through March 2005. Healthy women who underwent a primary cesarean delivery for breech presentation constituted a surrogate “planned cesarean group” considered to have undergone low-risk elective cesarean delivery, for comparison with an otherwise similar group of women who had planned to deliver vaginally.
Results
The planned cesarean group comprised 46 766 women v. 2 292 420 in the planned vaginal delivery group; overall rates of severe morbidity for the entire 14-year period were 27.3 and 9.0, respectively, per 1000 deliveries. The planned cesarean group had increased postpartum risks of cardiac arrest (adjusted odds ratio [OR] 5.1, 95% confidence interval [CI] 4.1–6.3), wound hematoma (OR 5.1, 95% CI 4.6–5.5), hysterectomy (OR 3.2, 95% CI 2.2–4.8), major puerperal infection (OR 3.0, 95% CI 2.7–3.4), anesthetic complications (OR 2.3, 95% CI 2.0–2.6), venous thromboembolism (OR 2.2, 95% CI 1.5–3.2) and hemorrhage requiring hysterectomy (OR 2.1, 95% CI 1.2–3.8), and stayed in hospital longer (adjusted mean difference 1.47 d, 95% CI 1.46–1.49 d) than those in the planned vaginal delivery group, but a lower risk of hemorrhage requiring blood transfusion (OR 0.4, 95% CI 0.2–0.8). Absolute risk increases in severe maternal morbidity rates were low (e.g., for postpartum cardiac arrest, the increase with planned cesarean delivery was 1.6 per 1000 deliveries, 95% CI 1.2–2.1). The difference in the rate of in-hospital maternal death between the 2 groups was nonsignificant (p = 0.87).
Interpretation
Although the absolute difference is small, the risks of severe maternal morbidity associated with planned cesarean delivery are higher than those associated with planned vaginal delivery. These risks should be considered by women contemplating an elective cesarean delivery and by their physicians.
doi:10.1503/cmaj.060870
PMCID: PMC1800583  PMID: 17296957
18.  Severe maternal morbidity in Canada, 1991–2001 
Background
Although death rates are often used to monitor the quality of health care, in industrialized countries maternal deaths have become rare. Severe maternal morbidity has therefore been proposed as a supplementary indicator for surveillance of the quality of maternity care. Our purpose in this study was to describe severe maternal morbidity in Canada over a 10-year period, among women with or without major pre-existing conditions.
Methods
We carried out a retrospective cohort study of severe maternal morbidity involving 2 548 824 women who gave birth in Canadian hospitals between 1991 and 2000. Thirteen conditions that may threaten the life of the mother (e.g., eclampsia) and 11 major pre-existing chronic conditions (e.g., diabetes) that could be identified from diagnostic codes were noted.
Results
The overall rate of severe maternal morbidity was 4.38 per 1000 deliveries. The fatality rate among these women was 158 times that of the entire sample. Rates of venous thromboembolism, uterine rupture, adult respiratory distress syndrome, pulmonary edema, myocardial infarction, severe postpartum hemorrhage requiring hysterectomy, and assisted ventilation increased substantially from 1991 to 2000. The presence of major pre-existing conditions increased the risk of severe maternal morbidity to 6-fold.
Interpretation
Severe maternal morbidity occurs in about 1 of 250 deliveries in Canada, with marked recent increases in certain morbid conditions such as pulmonary edema, myocardial infarction, hemorrhage requiring hysterectomy, and the use of assisted ventilation.
doi:10.1503/cmaj.045156
PMCID: PMC1216316  PMID: 16186582

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