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1.  Contribution of prepregnancy body mass index and gestational weight gain to adverse neonatal outcomes: population attributable fractions for Canada 
Background
Low or high prepregnancy body mass index (BMI) and inadequate or excess gestational weight gain (GWG) are associated with adverse neonatal outcomes. This study estimates the contribution of these risk factors to preterm births (PTBs), small-for-gestational age (SGA) and large-for-gestational age (LGA) births in Canada compared to the contribution of prenatal smoking, a recognized perinatal risk factor.
Methods
We analyzed data from the Canadian Maternity Experiences Survey. A sample of 5,930 women who had a singleton live birth in 2005-2006 was weighted to a nationally representative population of 71,200 women. From adjusted odds ratios, we calculated population attributable fractions to estimate the contribution of BMI, GWG and prenatal smoking to PTB, SGA and LGA infants overall and across four obstetric groups.
Results
Overall, 6% of women were underweight (<18.5 kg/m2) and 34.4% were overweight or obese (≥25.0 kg/m2). More than half (59.4%) gained above the recommended weight for their BMI, 18.6% gained less than the recommended weight and 10.4% smoked prenatally. Excess GWG contributed more to adverse outcomes than BMI, contributing to 18.2% of PTB and 15.9% of LGA. Although the distribution of BMI and GWG was similar across obstetric groups, their impact was greater among primigravid women and multigravid women without a previous PTB or pregnancy loss. The contributions of BMI and GWG to PTB and SGA exceeded that of prenatal smoking.
Conclusions
Maternal weight, and GWG in particular, contributes significantly to the occurrence of adverse neonatal outcomes in Canada. Indeed, this contribution exceeds that of prenatal smoking for PTB and SGA, highlighting its public health importance.
doi:10.1186/s12884-015-0452-0
PMCID: PMC4326407  PMID: 25652811
Population attributable fraction; Maternal weight; Preterm birth; Small-for-gestational age; Large-for-gestational age
2.  Pre-pregnancy Body Mass Index (BMI) and delivery outcomes in a Canadian population 
Background
Worldwide there has been a dramatic increase in the prevalence of overweight and obesity in women of childbearing age. Growing evidence suggests that maternal overweight and obesity is associated with poor maternal and perinatal outcomes. This study evaluated the impact of maternal pre-pregnancy overweight and obesity on pregnancy, labour and delivery outcomes in a cohort of women with term, singleton pregnancies cared for by family physicians in community based practices.
Methods
This study is a secondary analysis of the All Our Babies Cohort, a prospective, community-based pregnancy cohort in Calgary, Alberta. Maternal self-reported data on height and pre-pregnancy weight from term, singleton, cephalic pregnancies (n = 1996) were linked to clinical data on pregnancy and birth events retrieved from electronic health records. Descriptive and bivariate regression analysis were used to compare pregnancy and birth outcomes between women categorized as normal weight, overweight and obese based on the pre-pregnancy BMI. Multinomial regression analysis stratified by type of labour onset examined the association between pre-pregnancy BMI and mode of delivery controlling for maternal age, pre-existent health conditions, parity, fertility treatments, history of C-section and pregnancy complications.
Results
The cohort consisted of 65.8% normal weight, 23.6% overweight and 10.6% obese women. Women with increased pre-pregnancy BMI were more likely to develop pregnancy complications such as preeclampsia (OR 3.5, CI 2.0-4.6 for overweight; OR 5.3, CI 3.3-8.5 for obese) and gestational diabetes (OR 3.0, CI 1.8-5.0 for overweight; OR 6.5, CI 3.7-11.2 for obese) than normal weight women. Spontaneous onset of labour was recorded in 71.2% of women with normal pre-pregnancy BMI, whereas 39.3% of overweight and 49% of obese women had their labour induced. For women with spontaneous labour, pre-pregnancy BMI was not a significant risk factor for mode of delivery, controlling for covariates. Among women with induced labor, obesity was a significant risk factor for delivery by C-section (adjusted OR 2.2; CI 1.2-4.1).
Conclusions
Even among women with term, singleton pregnancies obtaining prenatal care in community-based settings, obese women who undergo labour induction are at increased risk of obstetrical interventions at delivery. These findings highlight the importance of tailored maternal care in pregnancy and at delivery of pregnant women with increased BMI in order to improve the outcomes and wellbeing of these women and their children.
Electronic supplementary material
The online version of this article (doi:10.1186/s12884-014-0422-y) contains supplementary material, which is available to authorized users.
doi:10.1186/s12884-014-0422-y
PMCID: PMC4300169  PMID: 25528667
Pregnancy; Obesity; Overweight; Labour induction; Caesarean section; Pregnancy complications
3.  Early childhood risk and resilience factors for behavioural and emotional problems in middle childhood 
BMC Pediatrics  2014;14:166.
Background
Mental disorders in childhood have a considerable health and societal impact but the associated negative consequences may be ameliorated through early identification of risk and protective factors that can guide health promoting and preventive interventions. The objective of this study was to inform health policy and practice through identification of demographic, familial and environmental factors associated with emotional or behavioural problems in middle childhood, and the predictors of resilience in the presence of identified risk factors.
Methods
A cohort of 706 mothers followed from early pregnancy was surveyed at six to eight years post-partum by a mail-out questionnaire, which included questions on demographics, children’s health, development, activities, media and technology, family, friends, community, school life, and mother’s health.
Results
Although most children do well in middle childhood, of 450 respondents (64% response rate), 29.5% and 25.6% of children were found to have internalising and externalising behaviour problem scores in the lowest quintile on the NSCLY Child Behaviour Scales. Independent predictors for problem behaviours identified through multivariable logistic regression modelling included being male, demographic risk, maternal mental health risk, poor parenting interactions, and low parenting morale. Among children at high risk for behaviour problems, protective factors included high maternal and child self-esteem, good maternal emotional health, adequate social support, good academic performance, and adequate quality parenting time.
Conclusions
These findings demonstrate that several individual and social resilience factors can counter the influence of early adversities on the likelihood of developing problem behaviours in middle childhood, thus informing enhanced public health interventions for this understudied life course phase.
doi:10.1186/1471-2431-14-166
PMCID: PMC4083129  PMID: 24986740
4.  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
6.  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
8.  Mental health outcomes of mothers who conceived using fertility treatment 
Reproductive Health  2014;11:19.
Objective
To compare the proportion of women with self-reported depression and anxiety symptoms at four months postpartum between mothers of singletons who conceived spontaneously and mothers who conceived with the aid of fertility treatment.
Methods
The sample used for this study was drawn from The “All Our Babies Study”, a community-based prospective cohort of 1654 pregnant women who received prenatal care in Calgary, Alberta. This analysis included women utilizing fertility treatment and a randomly selected 1:2 comparison group. The data was collected via three questionnaires, two of which were mailed to the participants during pregnancy and one at four months postpartum. Symptoms of depression and anxiety at four months postpartum were measured using the Edinburg Postnatal Depression Scale and the Spielberger State Anxiety Inventory. Secondary outcomes of parenting morale and perceived stress were also evaluated. Descriptive statistics were used to characterize the population. Chi square tests and in cases of small cell sizes, Fisher Exact Tests were used to assess differences in postpartum mental health symptomatology between groups.
Results
Seventy-six participants (5.9%) conceived using a form of fertility treatment. At four months postpartum, no significant differences were observed in the proportions reporting excessive depression symptoms (2.6% vs. 5.3%, p = 0.50), anxiety (8.1% vs. 16.9%, p = 0.08) or high perceived stress scores (7.9% vs. 13.3%, p = 0.23). Women who conceived with fertility treatment were less likely to score low on parenting morale compared to women who conceived spontaneously and this was particularly evident in primiparous women (12.5% vs. 33.8%, p = 0.01). There were no group differences in proportions reporting low parenting morale in multiparous women.
Conclusion
This study suggests that at four months postpartum, the proportion of women who experience elevated symptoms of depression, anxiety or perceived stress do not differ between mothers who conceive using fertility treatment and those who conceive spontaneously. Parenting morale at four months postpartum is significantly lower in primiparous mothers conceiving spontaneously compared to those who conceive with fertility treatment.
doi:10.1186/1742-4755-11-19
PMCID: PMC3996036  PMID: 24581007
Assisted reproductive technologies; In vitro fertilization; Postpartum depression; Anxiety; Fertility treatment
9.  The Public’s views of mental health in pregnant and postpartum women: a population-based study 
Background
We used population-based data to determine the public’s views of prenatal and postnatal mental health and to identify predictors of those views.
Methods
A computer-assisted telephone survey was conducted by the Population Health Laboratory (University of Alberta) with a random sample of participants from the province of Alberta, Canada. Respondents were eligible to participate if they were: 1) ≥18 years; and 2) contacted by direct dialing. Questions were drawn from the Perinatal Depression Monitor, an Australian population-based survey on perinatal mental health; additional questions were developed and tested to reflect the Canadian context. Descriptive and multivariable regression analyses were conducted.
Results
Among the 1207 respondents, 74.7% had post-secondary education, 16.3% were in childbearing years, and over half (57.4%) reported knowing a woman who had experienced postpartum depression. Significantly more respondents had high levels of knowledge of postnatal (87.4%) than prenatal (70.5%) mental health (p < .01). Only 26.6% of respondents accurately identified that prenatal anxiety/depression could negatively impact child development. Personal knowledge of a woman with postpartum depression was a significant predictor of prenatal and postnatal mental health knowledge.
Conclusions
While the public’s knowledge of postnatal mental health is high, knowledge regarding prenatal mental health and its influence on child development is limited. Strategies for improving perinatal mental health literacy should target these knowledge deficits.
doi:10.1186/1471-2393-14-84
PMCID: PMC3941946  PMID: 24564783
Pregnancy; Postpartum; Mental health; Public views; Depression; Anxiety
10.  Public views of acceptability of perinatal mental health screening and treatment preference: a population based survey 
Background
At a prevalence rate of 13-25%, mental health problems are among the most common morbidities of the prenatal and postnatal periods. They have been associated with increased risk of preterm birth and low birthweight, child developmental delay, and poor child mental health. However, very few pregnant and postpartum women proactively seek help or engage in treatment and less than 15% receive needed mental healthcare. While system-related barriers limit accessibility and availability of mental health services, personal barriers, such as views of mental health and its treatment, are also cited as significant deterrents of obtaining mental healthcare. The purposes of this population-based study were to identify the public’s views regarding mental health screening and treatment in pregnant and postpartum women, and to determine factors associated with those views.
Methods
A computer-assisted telephone survey was conducted by the Population Research Laboratory with a random sample of adults in Alberta, Canada. Questions were drawn from the Perinatal Depression Monitor, an Australian population-based survey on perinatal mental health; additional questions were developed and tested to reflect the Canadian context. Interviews were conducted in English and were less than 30 minutes in duration. Descriptive and multivariable regression analyses were conducted.
Results
Among the 1207 respondents, 74.8% had post-secondary education, 16.3% were 18-34 years old, and two-thirds (66.1%) did not have children <18 years living at home. The majority of respondents strongly agreed/agreed that all women should be screened in the prenatal (63.0%) and postpartum periods (72.7%). Respondents reported that when seeking help and support their first choice would be a family doctor. Preferred treatments were talking to a doctor or midwife and counseling. Knowledge of perinatal mental health was the main factor associated with different treatment preferences.
Conclusions
The high acceptability of universal perinatal mental health screening among the public provides a strong message regarding the public value for routine screening during pregnancy and postpartum periods. Perinatal mental health literacy is the most prominent determinant of screening and treatment acceptability and preference. Efforts to enhance population literacy as part of a multifaceted perinatal mental health strategy may optimize pregnant and postpartum women’s mental health.
doi:10.1186/1471-2393-14-67
PMCID: PMC3925362  PMID: 24521267
Perinatal mental health; Screening; Acceptability; Treatment; Postpartum; Antenatal; Depression; Anxiety; Stress; Mental health literacy
11.  Comparison of sample characteristics in two pregnancy cohorts: community-based versus population-based recruitment methods 
Background
One of the biggest challenges for population health studies is the recruitment of participants. Questions that investigators have asked are “who volunteers for studies?” and “does recruitment method influence characteristics of the samples?” The purpose of this paper was to compare sample characteristics of two unrelated pregnancy cohort studies taking place in the same city, in the same time period, that employed different recruitment strategies, as well as to compare the characteristics of both cohorts to provincial and national statistics derived from the Maternity Experiences Survey (MES).
Methods
One pregnancy cohort used community-based recruitment (e.g. posters, pamphlets, interviews with community media and face-to-face recruitment in maternity clinics); the second pregnancy cohort used both community-based and population-based (a centralized system identifying pregnant women undergoing routine laboratory testing) strategies.
Results
The pregnancy cohorts differed in education, income, ethnicity, and foreign-born status (p < 0.01), but were similar for maternal age, BMI, and marital status. Compared to the MES, the lowest age, education, and income groups were under-represented, and the cohorts were more likely to be primiparous.
Conclusions
The findings suggest that non-stratified strategies for recruitment of participants will not necessarily result in samples that reflect the general population, but can reflect the target population of interest. Attracting and retaining young, low resource women into urban studies about pregnancy may require alternate and innovative approaches.
doi:10.1186/1471-2288-13-149
PMCID: PMC4029181  PMID: 24314150
Recruitment strategy; Community-based; Population-based; Cohort studies; Participant characteristics
12.  Maternal perceptions of partner support during breastfeeding 
Background
Many women find breastfeeding challenging to sustain beyond the first three postpartum months. Women rely on a variety of resources to aid and encourage breastfeeding, including ‘partner support’. Women’s perception of partner support during breastfeeding may influence maternal satisfaction and confidence but it remains understudied. We asked women about their perceptions of partner support during breastfeeding and measured the effect on maternal confidence, commitment, and satisfaction with respect to breastfeeding.
Methods
Using a descriptive, cross sectional design, we recruited 76 mothers from community health clinics in Calgary, Alberta. Participants completed a questionnaire addressing perceptions of partner support, the Breastfeeding Self-Efficacy Scale (BSES) measuring maternal confidence and ability to breastfeed, and the Hill and Humenick Lactation Scale (HHLS) measuring commitment, perceived infant satiety, and breastfeeding satisfaction. Descriptive analysis was performed on socio-demographic and survey responses. Multiple regression modeling was used to examine the association between partner support and breastfeeding outcomes.
Results
Women who reported active/positive support from their partners scored higher on the BSES (p < 0.019) than those reporting ambivalent/negative partner support when we controlled for previous breastfeeding experience and age of infant. There were no significant differences between the two groups of women on total score of HHLS or any of the subscales with respect to perceptions of partner support.
Conclusion
Mothers feel more capable and confident about breastfeeding when they perceive their partners are supportive by way of verbal encouragement and active involvement in breastfeeding activities. Mothers with partners who seemed ambivalent, motivated only by “what’s best for baby,” or provided negative feedback about breastfeeding, felt less confident in their ability to breastfeed. It is important that health care professionals appreciate the influence that positive and active partner support has upon the development of maternal confidence in breastfeeding, a known predictor for maintaining breastfeeding. Common support strategies could be communicated to both the partner and mother in the prenatal and postpartum periods. Health professionals can provide information, invite partners to become active learners and discuss supportive partner functions. Further research should address those functions that are perceived as most supportive by mothers and that partners are willing to perform.
doi:10.1186/1746-4358-8-4
PMCID: PMC3653816  PMID: 23651688
Breastfeeding; Perceived support; Partner
13.  Impact of prenatal care provider on the use of ancillary health services during pregnancy 
Background
Recent declines in the provision of prenatal care by family physicians and the integration of midwives into the Canadian health care system have led to a shift in the pattern of prenatal care provision; however it is unknown if this also impacts use of other health services during pregnancy. This study aimed to assess the impact of the type of prenatal care provider on the self-reported use of ancillary services during pregnancy.
Methods
Data for this study was obtained from the All Our Babies study, a community-based prospective cohort study of women’s experiences during pregnancy and the post-partum period. Chi-square tests and logistic regression were used to assess the association between type of prenatal care provider and use of ancillary health services in pregnancy.
Results
During pregnancy, 85.8% of women reported accessing ancillary health services. Compared to women who received prenatal care from a family physician, women who saw a midwife were less likely to call a nurse telephone advice line (OR = 0.30, 95% CI: 0.18-0.50) and visit the emergency department (OR = 0.47, 95% CI: 0.24-0.89), but were more likely receive chiropractic care (OR = 4.07, 95% CI: 2.49-6.67). Women who received their prenatal care from an obstetrician were more likely to visit a walk-in clinic (OR = 1.51, 95% CI: 1.11-2.05) than those who were cared for by a family physician.
Conclusions
Prenatal care is a complex entity and referral pathways between care providers and services are not always clear. This can lead to the provision of fragmented care and create opportunities for errors and loss of information. All types of care providers have a role in addressing the full range of health needs that pregnant women experience.
doi:10.1186/1471-2393-13-62
PMCID: PMC3599935  PMID: 23497179
Physician practice patterns; Pregnancy; Health services research
14.  A qualitative study of the experience of CenteringPregnancy group prenatal care for physicians 
BMC Pregnancy and Childbirth  2013;13(Suppl 1):S6.
Background
This study sought to understand the central meaning of the experience of group prenatal care for physicians who were involved in providing CenteringPregnancy through a maternity clinic in Calgary, Canada.
Method
The study followed the phenomenological qualitative tradition. Three physicians involved in group prenatal care participated in a one-on-one interview between November and December 2009. Two physicians participated in verification sessions. Interviews followed an open ended general guide and were audio recorded and transcribed. The purpose of the analysis was to identify meaning themes and the core meaning experienced by the physicians.
Results
Six themes emerged: (1) having a greater exchange of information, (2) getting to knowing, (3) seeing women get to know and support each other, (4) sharing ownership of care, (5) having more time, and (6) experiencing enjoyment and satisfaction in providing care. These themes contributed to the core meaning for physicians of “providing richer care.”
Conclusions
Physicians perceived providing better care and a better professional experience through CenteringPregnancy compared to their experience of individual prenatal care. Thus, CenteringPregnancy could improve work place satisfaction, increase retention of providers in maternity care, and improve health care for women.
doi:10.1186/1471-2393-13-S1-S6
PMCID: PMC3561144  PMID: 23445867
15.  The All Our Babies pregnancy cohort: design, methods, and participant characteristics 
BMC Pregnancy and Childbirth  2013;13(Suppl 1):S2.
Background
The prospective cohort study design is ideal for examining diseases of public health importance, as its inherent temporal nature renders it advantageous for studying early life influences on health outcomes and research questions of aetiological significance. This paper will describe the development and characteristics of the All Our Babies (AOB) study, a prospective pregnancy cohort in Calgary, Alberta, Canada designed to examine determinants of maternal, infant, and child outcomes and identify barriers and facilitators in health care utilization.
Methods
Women were recruited from health care offices, communities, and through Calgary Laboratory Services before 25 weeks gestation from May 2008 to December 2010. Participants completed two questionnaires during pregnancy, a third at 4 months postpartum, and are currently being followed-up with questionnaires at 12, 24, and 36 months. Data was collected on pregnancy history, demographics, lifestyle, health care utilization, physical and mental health, parenting, and child developmental outcomes and milestones. In addition, biological/serological and genetic markers can be extracted from collected maternal and cord blood samples.
Results
A total of 4011 pregnant women were eligible for recruitment into the AOB study. Of this, 3388 women completed at least one survey. The majority of participants were less than 35 years of age, Caucasian, Canadian born, married or in a common-law relationship, well-educated, and reported household incomes above the Calgary median. Women who discontinued after the first survey (n=123) were typically younger, non-Caucasian, foreign-born, had lower education and household income levels, were less likely to be married or in a common-law relationship, and had poor psychosocial health in early pregnancy. In general, AOB participants reflect the pregnant and parenting population at local and provincial levels, and perinatal indicators from the study are comparable to perinatal surveillance data.
Conclusions
The extensive and rich data collected in the AOB cohort provides the opportunity to answer complex questions about the relationships between biology, early experiences, and developmental outcomes. This cohort will contribute to the understanding of the biologic mechanisms and social/environmental pathways underlying associations between early and later life outcomes, gene-environment interactions, and developmental trajectories among children.
doi:10.1186/1471-2393-13-S1-S2
PMCID: PMC3561154  PMID: 23445747
16.  Comparing CenteringPregnancy® to standard prenatal care plus prenatal education 
BMC Pregnancy and Childbirth  2013;13(Suppl 1):S5.
Background
There is significant evidence to support the importance of prenatal care in preventing adverse outcomes such as preterm birth and low infant birth weight. Previous studies have indicated that the benefits of prenatal care are not evenly distributed throughout the social strata. In addition, emerging evidence suggests that among particular populations, rates of preterm birth are unchanged or increasing. This suggests that an alternate care model is necessary, one that seeks to addresses some of the myriad of social factors that also contribute to adverse birth outcomes. In previous studies, the group prenatal care model CenteringPregnancy® had been shown to reduce adverse birth outcomes, but to date, no comparison had been made with a model that included prenatal education. This study sought to investigate whether any significant difference remained within the comparison groups when both models accounted for social factors.
Methods
This analysis was based on survey data collected from a prospective cohort of pregnant women through the All Our Babies Study in Calgary, Alberta.
Results
At baseline, there were significant differences between the comparison groups in their psychosocial health, with the women in the CenteringPregnancy® group scoring higher levels of depressive symptoms, stress and anxiety. At four months postpartum, the differences between the groups were no longer significant. Conclusions: These results suggest that CenteringPregnancy® can recruit and retain a demographically vulnerable group of women with a constellation of risk factors for poor pregnancy and birth outcomes, including poverty, language barriers and poor mental health. Post program, the rates of stress, anxiety and depression were similar to other women with more social and financial advantage. These findings suggest that CenteringPregnancy® may be a community based care strategy that contributes to improved mental health, knowledge, and behaviours to optimize outcomes for mothers and children.
doi:10.1186/1471-2393-13-S1-S5
PMCID: PMC3561159  PMID: 23445830
18.  Validation of Canadian mothers’ recall of events in labour and delivery with electronic health records 
BMC Pregnancy and Childbirth  2013;13(Suppl 1):S3.
Background
Maternal report of events that occur during labour and delivery are used extensively in epidemiological research; however, the validity of these data are rarely confirmed. This study aimed to validate maternal self-report of events that occurred in labour and delivery with data found in electronic health records in a Canadian setting.
Methods
Data from the All Our Babies study, a prospective community-based cohort of women’s experiences during pregnancy, were linked to electronic health records to assess the validity of maternal recall at four months post-partum of events that occurred during labour and delivery. Sensitivity, specificity and kappa scores were calculated. Results were stratified by maternal age, gravidity and educational attainment.
Results
Maternal recall at four months post-partum was excellent for infant characteristics (gender, birth weight, gestational age, multiple births) and variables related to labour and delivery (mode of delivery, epidural, labour induction) (sensitivity and specificity >85%). Women who had completed a university degree had significantly better recall of labour induction and use of an epidural.
Conclusion
Maternal recall of infant characteristics and events that occurred during labour and delivery is excellent at four months post-partum and is a valid source of information for research purposes.
doi:10.1186/1471-2393-13-S1-S3
PMCID: PMC3561172  PMID: 23445768
19.  Prenatal micronutrient supplementation and postpartum depressive symptoms in a pregnancy cohort 
Background
Postpartum depression is a serious problem for women and their offspring. Micronutrient supplements are recommended for pregnant women because of their documented protective effects for the offspring, but their potential beneficial effects on maternal mental health are unknown. This study investigated the association between prenatal micronutrient supplementation and the risk for symptoms of postpartum depression in a longitudinal pregnancy cohort from the Alberta Pregnancy Outcomes and Nutrition (APrON) study.
Methods
Participants came from a cohort of the first 600 APrON women. Supplemental nutrient intake and symptoms of depression (measured with the Edinburgh Postnatal Depression Scale (EPDS)) were collected at each trimester and 12 weeks postpartum.
Results
Of the 475 participants who completed the EPDS at least twice in pregnancy and at 12 weeks postpartum, 416 (88%) scored <10 and 59 (12%) scored ≥10, where an EPDS ≥10 is considered to be “at least probable minor depression”. Mean nutrient intakes from supplements were higher in women with lower EPDS scores, particularly selenium (p = 0.0015) and omega-3s (p = 0.01). Bivariate analyses showed that several demographic and social/lifestyle variables were associated with EPDS ≥10: not having been born in Canada (p = 0.01), greater number of chronic conditions (p = 0.05), greater number of stressful life events during this pregnancy (p = 0.02), and lower prenatal and postnatal support (p = 0.0043 and p = 0.0001, respectively). Adjusting for covariates and nutrients known to be associated with postpartum depression, logistic regression showed that having a prenatal EPDS ≥ 10 increased the odds of postpartum depressive symptoms (second and third trimester OR = 3.29, 95% CI = 1.55 - 7.01, p = 0.004 and OR = 4.26, 95% CI = 2.05 - 8.85, p < 0.0001, respectively), while prenatal supplemental selenium (per 10 mcg, OR = 0.76, 95% CI = 0.74 - 0.78, p = 0.0019) and postnatal social support (OR = 0.87, 95% CI = 0.78 - 0.97, p = 0.0015) were protective.
Conclusions
Multiple factors, including supplementary selenium intake, are associated with the risk of postpartum depressive symptoms. Future research on dietary supplementation in pregnancy with special attention to selenium intake is warranted.
doi:10.1186/1471-2393-13-2
PMCID: PMC3585741  PMID: 23324464
Postpartum depression; Dietary supplements; Selenium; Omega-3
20.  Influence of interpersonal violence on maternal anxiety, depression, stress and parenting morale in the early postpartum: a community based pregnancy cohort study 
Background
Research has shown that exposure to interpersonal violence is associated with poorer mental health outcomes. Understanding the impact of interpersonal violence on mental health in the early postpartum period has important implications for parenting, child development, and delivery of health services. The objective of the present study was to determine the impact of interpersonal violence on depression, anxiety, stress, and parenting morale in the early postpartum.
Methods
Women participating in a community-based prospective cohort study (n = 1319) completed questionnaires prior to 25 weeks gestation, between 34–36 weeks gestation, and at 4 months postpartum. Women were asked about current and past abuse at the late pregnancy data collection time point. Postpartum depression, anxiety, stress, and parenting morale were assessed at 4 months postpartum using the Edinburgh Postnatal Depression Scale, the Spielberger State Anxiety Index, the Cohen Perceived Stress Scale, and the Parenting Morale Index, respectively. The relationship between interpersonal violence and postpartum psychosocial health status was examined using Chi-square analysis (p < 0.05) and multivariable logistic regression.
Results
Approximately 30% of women reported one or more experience of interpersonal violence. Sixteen percent of women reported exposure to child maltreatment, 12% reported intimate partner violence, and 12% reported other abuse. Multivariable logistic regression analysis found that a history of child maltreatment had an independent effect on depression in the postpartum, while both child maltreatment and intimate partner violence were associated with low parenting morale. Interpersonal violence did not have an independent effect on anxiety or stress in the postpartum.
Conclusion
The most robust relationships were seen for the influence of child maltreatment on postpartum depression and low parenting morale. By identifying women at risk for depression and low parenting morale, screening and treatment in the prenatal period could have far-reaching effects on postpartum mental health thus benefiting new mothers and their families in the long term.
doi:10.1186/1471-2393-12-153
PMCID: PMC3544728  PMID: 23241428
Interpersonal violence; Pregnancy cohort; Postpartum mental health; Parenting morale
21.  A Comparison Between Late Preterm and Term Infants on Breastfeeding and Maternal Mental Health 
Maternal and Child Health Journal  2012;17(8):1468-1477.
The objective of this study was to compare breastfeeding, postpartum mental health, and health service utilization between a group of late preterm (LP) maternal infant pairs and term counterparts. Data was drawn from a prospective community-based cohort in Calgary, Alberta. Bivariate and multivariable analyses were performed. LP infants were more likely to have had a longer median length of stay after birth (P < 0.001) and a higher re-hospitalization rate at 4-months (P < 0.001) compared to term infants. Mothers of LP infants were more likely to report immediate breastfeeding difficulties (P < 0.001) and earlier cessation of breastfeeding at 4-months postpartum (P = 0.008). Multivariable analyses revealed that LP status was an independent risk factor for excessive symptoms of maternal anxiety (OR = 2.07; 95 % CI = 1.08,3.98), but not for depression, stress, or low parenting morale. LP infants and their families are a vulnerable population with unique developmental trajectories. Further longitudinal research is required.
doi:10.1007/s10995-012-1153-1
PMCID: PMC3785180  PMID: 23054457
Breastfeeding; Late preterm; Maternal mental health; Postpartum
22.  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
23.  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
24.  Getting more than they realized they needed: a qualitative study of women's experience of group prenatal care 
Background
Pregnant women in Canada have traditionally received prenatal care individually from their physicians, with some women attending prenatal education classes. Group prenatal care is a departure from these practices providing a forum for women to experience medical care and child birth education simultaneously and in a group setting. Although other qualitative studies have described the experience of group prenatal care, this is the first which sought to understand the central meaning or core of the experience. The purpose of this study was to understand the central meaning of the experience of group prenatal care for women who participated in CenteringPregnancy through a maternity clinic in Calgary, Canada.
Methods
The study used a phenomenological approach. Twelve women participated postpartum in a one-on-one interview and/or a group validation session between June 2009 and July 2010.
Results
Six themes emerged: (1) "getting more in one place at one time"; (2) "feeling supported"; (3) "learning and gaining meaningful information"; (4) "not feeling alone in the experience"; (5) "connecting"; and (6) "actively participating and taking on ownership of care". These themes contributed to the core phenomenon of women "getting more than they realized they needed". The active sharing among those in the group allowed women to have both their known and subconscious needs met.
Conclusions
Women's experience of group prenatal care reflected strong elements of social support in that women had different types of needs met and felt supported. The findings also broadened the understanding of some aspects of social support beyond current theories. In a contemporary North American society, the results of this study indicate that women gain from group prenatal care in terms of empowerment, efficiency, social support and education in ways not routinely available through individual care. This model of care could play a key role in addressing women's needs and improving health outcomes.
doi:10.1186/1471-2393-12-17
PMCID: PMC3364900  PMID: 22436393
Canada; Prenatal care; Pregnant women; Women's health; Social support
25.  Estimating the prevalence of infertility in Canada 
BACKGROUND
Over the past 10 years, there has been a significant increase in the use of assisted reproductive technologies in Canada, however, little is known about the overall prevalence of infertility in the population. The purpose of the present study was to estimate the prevalence of current infertility in Canada according to three definitions of the risk of conception.
METHODS
Data from the infertility component of the 2009–2010 Canadian Community Health Survey were analyzed for married and common-law couples with a female partner aged 18–44. The three definitions of the risk of conception were derived sequentially starting with birth control use in the previous 12 months, adding reported sexual intercourse in the previous 12 months, then pregnancy intent. Prevalence and odds ratios of current infertility were estimated by selected characteristics.
RESULTS
Estimates of the prevalence of current infertility ranged from 11.5% (95% CI 10.2, 12.9) to 15.7% (95% CI 14.2, 17.4). Each estimate represented an increase in current infertility prevalence in Canada when compared with previous national estimates. Couples with lower parity (0 or 1 child) had significantly higher odds of experiencing current infertility when the female partner was aged 35–44 years versus 18–34 years. Lower odds of experiencing current infertility were observed for multiparous couples regardless of age group of the female partner, when compared with nulliparous couples.
CONCLUSIONS
The present study suggests that the prevalence of current infertility has increased since the last time it was measured in Canada, and is associated with the age of the female partner and parity.
doi:10.1093/humrep/der465
PMCID: PMC3279129  PMID: 22258658
prevalence; infertility; epidemiology; risk factors

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