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Summary: Background: Group B Streptococcus (GBS) significantly contributes to neonatal sepsis and meningitis, with varying disease rates reported globally and limited population-based data. We estimated infant GBS disease burden in Ontario, Canada and assessed the association of maternal GBS screening (35–37 weeks' gestation) and intrapartum antibiotic prophylaxis (IAP) provision with infant disease rates. Methods: Our population-based cohort study included pregnant individuals and their offspring from April 2012 to March 2018, utilising the provincial birth registry linked to health administrative data. GBS cases were ascertained through culture results and diagnostic codes. We calculated incidence rates for early-onset disease (EOD: 0–6 days), late-onset disease (LOD: 7–89 days), and ultra-LOD (ULOD: 90–365 days). Adjusted incidence rate ratios (aIRR) were derived via log-binomial regression to compare infant GBS rates according to screening and IAP-receipt. Findings: Among 776,148 liveborn infants, we identified 803 with GBS, with multiples exhibiting a threefold incidence increase. Incidence rates of EOD, LOD and ULOD were 0.49, 0.46 and 0.07 per 1000 livebirths, respectively. Of eligible pregnancies, 94% were screened; 23% screened positive, and 81% of them received IAP. Nearly 12% of term EOD infants had mothers who missed IAP despite screening positive. Maternal screening was associated with lower rates of any infant GBS disease (aIRR: 0.60; 95% CI: 0.45, 0.80). Among screen-positive births, IAP-receipt was associated with reduced rates of EOD (aIRR: 0.72, 95% CI: 0.48, 1.29) and LOD/ULOD (aIRR: 0.69; 95% CI: 0.46, 1.05), but confidence intervals included 1.0. Interpretation: Our study, the largest Canadian investigation into infant GBS disease, highlights both widespread adoption and ongoing challenges of the current prevention strategy. Funding: Canadian Institutes of Health Research.

Abstract Introduction Gestational diabetes mellitus (GDM) is associated with adverse perinatal outcomes. Approaches to screening for GDM continue to evolve, introducing potential variability of care. This study explored the impact of these variations on GDM counselling and screening from the perspectives of pregnant individuals. Methods Following a Corbin and Strauss approach to qualitative, grounded theory we recruited 28 individuals from three cities in Ontario, Canada who had a singleton pregnancy under the care of either a midwife, family physician or obstetrician. Convenience and purposive sampling techniques were used. Semi‐structured telephone interviews were conducted and transcribed verbatim between March and December 2020. Transcripts were analysed inductively resulting in codes, categories and themes. Results Three themes were derived from the data about GDM screening and counselling: ‘informing oneself’, ‘deciding’ and ‘screening’. All participants, regardless of geographical region, or antenatal care provider, moved through these three steps during the GDM counselling and screening process. Differences in counselling approaches between pregnancy care providers were noted throughout the ‘informing’ and ‘deciding’ stages of care. Factors influencing these differences included communication, healthcare autonomy and patient motivation to engage with health services. No differences were noted within care provider groups across the three geographic regions. Participant experiences of GDM screening were influenced by logistical challenges and personal preferences towards testing. Conclusion Informing oneself about GDM may be a crucial step for facilitating decision‐making and screening uptake, with an emphasis on information provision to facilitate patient autonomy and motivation. Patient or Public Contribution Participants of our study included patients and service users. Participants were actively involved in the study design due to the qualitative, patient‐centred nature of the research methods employed. Analysis of results was structured according to the emergent themes of the data which were grounded in patient perspectives and experiences.

Abstract Postpartum haemorrhage (PPH) is a leading cause of maternal morbidity and mortality. While tranexamic acid (TXA) reduces bleeding and transfusion requirements in established PPH, we sought to determine the feasibility of conducting a fully powered trial assessing the effect of prophylactic tranexamic acid, prior to PPH onset, in a Canadian Obstetric setting. With institutional and Health Canada approval, consenting, eligible parturients (singleton, > 32 weeks gestation, vaginal or caesarian delivery) were randomly assigned to receive TXA (1 g intravenously) or placebo (0.9% saline) prior to delivery. Participants, investigators, data collectors/adjudicators, and analysis was blinded. The primary outcome was administration of study intervention to > 85% of randomized individuals. Secondary outcomes included recruitment rate (feasibility) and safety outcomes. Over 8 months, 611 were approached, 35 consented, and 27 randomized (14 TXA, 13 placebo). 89% of randomized participants received the assigned intervention. Recruitment fell below feasibility (23% target). No serious adverse outcomes occurred. Our pilot trial in a Canadian Obstetric setting was unable to demonstrate feasibility to conduct a large, multicentre trial to examine prophylactic use of tranexamic for PPH secondary to the complex regulatory requirements associated with a trial for an off-label, but commonly utilized intervention. These challenges should inform stakeholders on the resources and challenges of conducting future trials using off-label interventions. Trial registration: www.clinicaltrials.gov , NCT03069859 (03/03/2017).

During the rapid deployment of COVID-19 vaccines in 2021, safety concerns may have led some pregnant individuals to postpone vaccination until after giving birth. This study aimed to describe temporal patterns and factors associated with COVID-19 vaccine series initiation after recent pregnancy in Ontario, Canada. Using the provincial birth registry linked with the COVID-19 vaccine database, we identified all individuals who gave birth between January 1 and December 31, 2021, and had not yet been vaccinated by the end of pregnancy, and followed them to June 30, 2022 (follow-up ranged from 6 to 18 months). We used cumulative incidence curves to describe COVID-19 vaccine initiation after pregnancy and assessed associations with sociodemographic, pregnancy-related, and health behavioral factors using Cox proportional hazards regression to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI). Among 137,198 individuals who gave birth in 2021, 87,376 (63.7%) remained unvaccinated at the end of pregnancy; of these, 65.0% initiated COVID-19 vaccination by June 30, 2022. Lower maternal age (

Objective To assess risk of adverse pregnancy, fetal, and neonatal outcomes after a third dose (first booster dose) of covid-19 vaccine during pregnancy among individuals who had completed both doses of primary covid-19 vaccine series before pregnancy.Design Population based, retrospective cohort study.Setting Ontario, Canada, from 20 December 2021 to 31 August 2022.Participants Individuals were included if they were pregnant with an expected date of delivery from 20 December 2021 (start date of third dose eligibility for everyone ≥18 years) to 31 August 2022, who had completed the two doses of primary covid-19 messenger RNA vaccine series before pregnancy, and became eligible for a third dose (≥six months since dose two) before the end of pregnancy.Main outcome measures Pregnancy outcomes included hypertensive disorders of pregnancy, placental abruption, caesarean delivery, chorioamnionitis, and postpartum hemorrhage. Fetal and neonatal outcomes included stillbirth, preterm birth, admission to neonatal intensive care unit for >24 h, newborn 5 min Apgar score

Gestational diabetes mellitus (GDM) is associated with adverse health outcomes for the pregnant individual and their baby. Screening approaches for GDM have undergone several iterations, introducing variability in practice among healthcare providers. As such, our study aimed to explore the views of antenatal providers regarding their practices of, and counseling experiences on the topic of, GDM screening in Ontario. We conducted a qualitative, grounded theory study. The study population included antenatal providers (midwives, family physicians, and obstetricians) practicing in Hamilton, Ottawa, or Sudbury, Ontario. Semi-structured telephone interviews were conducted and transcribed verbatim. Transcripts were analyzed using inductive coding upon which codes, categories, and themes were developed to generate a theory grounded in the data. Twenty-two participants were interviewed. Using the social-ecological theory, we created a model outlining four contextual levels that shaped the experiences of GDM counseling and screening: Intrapersonal factors included beliefs, knowledge, and skills; interpersonal factors characterized the patient-provider interactions; organizational strengths and challenges shaped collaboration and health services infrastructure; and finally, guidelines and policies were identified as systemic barriers to health care access and delivery. A focus on patient-centered care was a guiding principle for all care providers and permeated all four levels of the model. Patient-centered care and close attention to barriers and facilitators across intrapersonal, interpersonal, organizational, and policy domains can minimize the impact of variations in GDM screening guidelines. Among care providers, there is a desire for additional skill development related to GDM counseling, and for national consensus on optimal screening guidelines.

Abstract Background Estimation of fetal weight (EFW) by ultrasound is useful in clinical decision-making. Numerous formulas for EFW have been published but have not been validated in pregnancies complicated by preterm premature rupture of membranes (PPROM). The purpose of this study is to compare the accuracy of EFW formulas in patients with PPROM, and to further evaluate the performance of the most commonly used formula - Hadlock IV. Methods A retrospective cohort study of women with singleton gestations and PPROM, admitted to a single tertiary center between 2005 and 2017 from 220/7–330/7 (n = 565). All women had an EFW within 14 days of delivery by standard biometry (biparietal diameter, head circumference, abdominal circumference and femur length). The accuracy of previously published 21 estimated EFW formulas was assessed by comparing the Pearson correlation with actual birth weight, and calculating the random error, systematic error, proportion of estimates within 10% of birth weight, and Euclidean distance. Results The mean gestational was 26.8 ± 2.4 weeks at admission, and 28.2 ± 2.6 weeks at delivery. Most formulas were strongly correlated with actual birth weight (r > 0.9 for 19/21 formulas). Mean systematic error was − 4.30% and mean random error was 14.5%. The highest performing formula, by the highest proportion of estimates and lowest Euclidean distance was Ott (1986), which uses abdominal and head circumferences, and femur length. However, there were minimal difference with all of the first 10 ranking formulas. The Pearson correlation coefficient for the Hadlock IV formula was strong at r = 0.935 (p

Introduction Severe maternal morbidity (SMM)—an unexpected pregnancy-associated maternal outcome resulting in severe illness, prolonged hospitalisation or long-term disability—is recognised by many, as the preferred indicator of the quality of maternity care, especially in high-income countries. Obtaining comprehensive details on events and circumstances leading to SMM, obtained through maternity units, could complement data from large epidemiological studies and enable targeted interventions to improve maternal health. The aim of this study is to assess the feasibility of gathering such data from maternity units across Canadian provinces and territories, with the goal of establishing a national obstetric survey system for SMM in Canada.Methods and analysis We propose a sequential explanatory mixed-methods study. We will first distribute a cross-sectional survey to leads of all maternity units across Canada to gather information on (1) Whether the unit has a system for reviewing SMM and the nature and format of this system, (2) Willingness to share anonymised data on SMM by direct entry using a web-based platform and (3) Respondents’ perception on the definition and leading causes of SMM at a local level. This will be followed by semistructured interviews with respondent groups defined a priori, to identify barriers and facilitators for data sharing. We will perform an integrated analysis to determine feasibility outcomes, a narrative description of barriers and facilitators for data-sharing and resource implications for data acquisition on an annual basis, and variations in top-5 causes of SMM.Ethics and dissemination The study has been approved by the Mount Sinai and Hamilton Integrated Research Ethics Boards. The study findings will be presented at annual scientific meetings of the Society of Obstetricians and Gynaecologists of Canada, North American Society of Obstetric Medicine, and International Network of Obstetric Survey Systems and published in an open-access peer-reviewed Obstetrics and Gynaecology or General Internal Medicine journal.

Abstract Background Inappropriate gestational weight gain in pregnancy may negatively impact health outcomes for mothers and babies. While optimal gestational weight gain is often not acheived, effective counselling by antenatal health care providers is recommended. It is not known if gestational weight gain counselling practices differ by type of antenatal health care provider, namely, family physicians, midwives and obstetricians, and what barriers impede the delivery of such counselling. The objective of this study was to understand the counselling of family physicians, midwives and obstetricians in Ontario and what factors act as barriers and enablers to the provision of counselling about GWG. Methods Semi-structured interviews were conducted with seven family physicians, six midwives and five obstetricians in Ontario, Canada, where pregnancy care is universally covered. Convenience and purposive sampling techniques were employed. A grounded theory approach was used for data analysis. Codes, categories and themes were generated using NVIVO software. Results Providers reported that they offered gestational weight gain counselling to all patients early in pregnancy. Counselling topics included gestational weight gain targets, nutrition & exercise, gestational diabetes prevention, while dispelling misconceptions about gestational weight gain. Most do not routinely address the adverse outcomes linked to gestational weight gain, or daily caloric intake goals for pregnancy. The health care providers all faced similar barriers to counselling including patient attitudes, social and cultural issues, and accessibility of resources. Patient enthusiasm and access to a dietician motivated health care providers to provide more in-depth gestational weight gain counselling. Conclusion Reported gestational weight gain counselling practices were similar between midwives, obstetricians and family physicians. Antenatal knowledge translation tools for patients and health care providers are needed, and would seem to be suitable for use across all three types of health care provider specialties.

Objective: Ultrasound determination of chorionicity is poor in early pregnancy in China. In an effort to increase the accuracy rate of prompt chorionicity determination, clinical training was provided to primary care physicians. This study assesses the effects of implementing clinical guidelines on chorionicity determination. Methods: A multi-centered cohort study was conducted between January 2014 and June 2017 in 12 hospitals without fetal medicine centers. In 2014, the obstetricians and ultrasound physicians were trained in clinical practice and ultrasound examination relating to chorionicity determination. Linear and binary regression analyses were conducted to identify the effects of introducing the new protocols, including the diagnosis rate of chorionicty and perinatal outcomes, taking the data from 2014 as a baseline. Pregnancy outcomes were additionally adjusted for maternal age. Results: During the period of this study, 3,599 twin pregnancies from 12 centers were enrolled, and a total of 2,998 twin pregnancies were extracted. The rate of overall chorionicity determination, including antenatal and postpartum diagnosis, increased successively from 49.5% in 2014 to 93.5% in 2017 (P < 0.0001). The rate of ultrasonic chorionicity diagnosis before 14 weeks increased from 25.2% in 2014 to 65.0% in 2017 (P < 0.0001). These changes were associated with decreasing incidence of preterm birth, a lower risk of stillbirth, whether for one (P = 0.0456 in 2016) or two fetuses (P = 0.0470 in 2016; P = 0.0042 in 2017) and a decreased rate of admission to neonatal intensive care unit (43.0% in 2014, 37.4% in 2017; P = 0.0032). Conclusions: The implementation of a clinical practice guideline improved both overall and early chorionicity determinations. Regular training workshops of antenatal care are recommended to further promote capability in clinical diagnosis and treatment.

ObjectiveTo determine the impact of pre-pregnancy diabetes mellitus (D), obesity (O) and chronic hypertension (H) on preterm birth (PTB).MethodsRetrospective population-based cohort study in Ontario, Canada between 2012-2016. Women who had a singleton livebirth or stillbirth at > 20 weeks gestation were included in the cohort. Exposures of interest were D, O and H, individually, and in various combinations. The primary outcome was PTB at 241/7 to 366/7 weeks. PTB was further analyzed by spontaneous or provider-initiated, early (< 34 weeks) or late (34-37 weeks), and the co-presence of preeclampsia, large for gestational age (LGA), and small for gestational age (SGA). Multivariable Poisson regression models with robust error variance were used to generate relative risks (RR), further adjusted for maternal age and parity (aRR). Population attributable fractions (PAF) were calculated for each of the outcomes by exposure state.Results506,483 women were eligible for analysis. 30,139 pregnancies (6.0%) were complicated by PTB < 37 weeks, of which 7375 (24.5%) had D or O or H. Relative to women without D or O or H, the aRR for PTB < 37 weeks was higher for D (3.51; 95% CI 3.26-3.78) and H (3.81; 95% CI 3.55-4.10) than O (1.14; 95% CI 1.10-1.17). The combined state of DH was associated with a significantly higher aRR of PTB < 37 weeks (6.34; 95% CI 5.14-7.80) and < 34 weeks (aRR 10.33, 95% CI 6.96-15.33) than D alone. The risk of provider initiated PTB was generally higher than that for spontaneous PTB. Pre-pregnancy hypertension was associated with the highest risk for PTB with preeclampsia (aRR 45.42, 95% CI 39.69-51.99) and PTB with SGA (aRR 9.78, 95% CI 7.81-12.26) while pre-pregnancy diabetes was associated with increased risk for PTB with LGA (aRR 28.85, 95% CI 24.65-33.76).ConclusionCombinations of DOH significantly magnify the risk of PTB, especially provider initiated PTB, and PTB with altered fetal growth or preeclampsia.

Objective An increasing proportion of fetuses are exposed to antenatal corticosteroids (ACS). Despite their immediate beneficial effects, the long-term safety of ACS has been an ongoing source of concern. In the current study, we assessed the likelihood of neurodevelopmental problems among term infants exposed to ACS earlier in pregnancy compared with non-exposed term infants.Design Retrospective cohort study (2006–2011). Median duration of follow-up was 7.8 (IQR 6.4–9.2) years.Setting Population-based study, Ontario, Canada.Participants All live singleton infants born at term (≥370/7 weeks gestation) (n=529 205).Exposure ACS during pregnancy.Primary and secondary outcome measures A composite of diagnostic or billing codes reflecting proven or suspected neurodevelopmental problems during childhood including audiometry testing, visual testing or physician service claim with a diagnosis code related to a suspected neurocognitive disorder.Results At 5 years of age, the cumulative rate for the primary outcome was higher among infants exposed to ACS compared with non-exposed infants: 61.7% (3346/5423) vs 57.8% (302 520/523 782), respectively (p