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Background: Large-scale longitudinal studies with biological samples are needed to examine the associations between prenatal cannabis use and birth and developmental outcomes. Objectives: The aim of this study was to understand the feasibility and acceptability of collecting umbilical cord tissue for the purpose of cannabis use testing in a community sample. Design: This is a mixed methods research study consisted of a prospective cohort study and a qualitative descriptive study. Methods: This study was conducted in Vancouver, British Columbia between January 2021 and August 2022. Participants were recruited during pregnancy, and the umbilical cord tissues were collected at birth and tested for the presence of cannabinoids. After the completion of the study, participants completed an online open-ended questionnaire about their overall experience. Data were analyzed using descriptive and thematic analyses. Results: Among the 85 eligible individuals, 57 people (67%) consented to the study. The cord tissue was collected for 39 participants (68.4%). The collection rates for participants with vaginal, elective, and emergency cesarean delivery were 73.0%, 71.4%, and 53.8%, respectively, and for those with spontaneous and induced labor were 81.5% and 50%, respectively. Four (7.0%) and seven participants (12.3%) reported prenatal cannabis use in direct and probing self-report questions, respectively. The agreement between any self-report and cord tissue test was moderate (kappa 0.53, 95% confidence interval 0.06–0.99). Qualitative findings were classified into five themes. Conclusion: The collection of cord tissue was perceived acceptable by most participants. Implementation of collection protocols for complex labors, a central hospital unit to liaise direct communications and active participants' involvement might increase the feasibility of future studies. [ABSTRACT FROM AUTHOR]

Background: Rates of gestational diabetes are reported to be increasing in many jurisdictions, but the reasons for this are poorly understood. We sought to evaluate the relative contribution of screening practices for gestational diabetes (including completion and methods of screening) and population characteristics to risk of gestational diabetes in British Columbia, Canada, from 2005 to 2019. Methods: We used a population-based cohort from a provincial registry of perinatal data, linked to laboratory billing records. We used data on screening completion, screening method (1-step 75-g glucose test or 2-step approach of 50-g glucose screening test, followed by a diagnostic test for patients who screen positive) and demographic risk factors. We modelled predicted annual risk for gestational diabetes, sequentially adjusted for screening completion, screening method and risk factors. Results: We included 551 457 pregnancies in the study cohort. The incidence of gestational diabetes more than doubled over the study period, from 7.2% in 2005 to 14.7% in 2019. Screening completion increased from 87.2% in 2005 to 95.5% in 2019. Use of 1-step screening methods increased from 0.0% in 2005 to 39.5% in 2019 among those who were screened. Unadjusted models estimated a 2.04 (95% confidence interval [CI] 1.94–2.13) increased risk of gestational diabetes in 2019 (v. 2005). This increase was 1.89 (95% CI 1.81–1.98) after accounting for the rise in screening completion and 1.34 (95% CI 1.28–1.40) after accounting for changes in screening methods. Further accounting for demographic risk factors (e.g., age, body mass index, prenatal care) had a small impact (increase of 1.25, 95% CI 1.19–1.31). Interpretation: Most of the observed increase in the incidence of gestational diabetes was attributable to changes in screening practices (primarily changes in screening methods) rather than changing population factors. Our findings highlight the importance of understanding variation in screening practices when monitoring incidence rates for gestational diabetes. [ABSTRACT FROM AUTHOR]

Background: The aim of this retrospective population‐based cohort study was to determine whether the mode of delivery and maternal and neonatal outcomes differ between planned home VBAC (HBAC) and planned hospital VBAC. Methods: All midwifery clients with at least one prior cesarean birth delivered between April 2000 and March 2017 (N = 4741; n = 4180 planned hospital VBAC, n = 561 planned HBAC) were included. Multivariate binomial logistic regression analyses were conducted to calculate the odds ratios adjusted for the potential covariates. The primary outcome was the mode of delivery, and the secondary outcomes were uterine rupture/dehiscence, postpartum hemorrhage, nonintact perineum, episiotomy, obstetric trauma, Apgar score <7 at 5 minutes, neonatal resuscitation requiring positive pressure ventilation, neonatal intensive care unit admission, and a composite outcome of severe neonatal mortality and morbidity and maternal mortality and morbidity. Results: Planned HBAC was associated with a significant 39% decrease in the odds of having a cesarean birth (aOR 0.61, 95% CI 0.47‐0.79) adjusting for the prepregnancy and pregnancy characteristics. Severe adverse outcomes were relatively rare in both settings; thus, our study did not have sufficient power to detect the true differences associated with the place of birth. Conclusions: Home births for those eligible for VBACs and attended by registered midwives within an integrated health system were associated with higher vaginal birth rates compared with planned hospital VBACs. Severe adverse outcomes were relatively rare in both settings. [ABSTRACT FROM AUTHOR]

Purpose: Currently, people leaving prisons face concurrent risks from the COVID-19 pandemic and the overdose public health emergency. The closure or reduction of community services people rely on after release such as treatment centres and shelters has exacerbated the risks of poor health outcomes and harms. This paper aims to learn from peer health mentors (PHM) about changes to their work during overlapping health emergencies, as well as barriers and opportunities to support people leaving prison in this context. Design/methodology/approach: The Unlocking the Gates (UTG) Peer Health Mentoring Program supports people leaving prison in British Columbia during the first three days after release. The authors conducted two focus groups with PHM over video conference in May 2020. Focus groups were recorded and transcribed, and themes were iteratively developed using narrative thematic analysis. Findings: The findings highlighted the importance of peer health mentorship for people leaving prisons. PHM discussed increased opportunities for collaboration, ways the pandemic has changed how they are able to provide support, and how PHM are able to remain responsive and flexible to meet client needs. Additionally, PHM illuminated ways that COVID-19 has exacerbated existing barriers and identified specific actions needed to support client health, including increased housing and recovery beds, and tools for social and emotional well-being. Originality/value: This study contributes to our understanding of peer health mentorship during the COVID-19 pandemic from the perspective of mentors. PHM expertise can support release planning, improved health and well-being of people leaving prison and facilitate policy-supported pandemic responses. [ABSTRACT FROM AUTHOR]

Objectives: Preeclampsia is characterized by maternal systemic inflammation and coagulation activation, akin to the sepsis syndrome. Recombinant human activated protein C (rhAPC; drotrecogin alfa [activated]) may modify disease progression to safely prolong pregnancies and improve perinatal outcomes. Both maternal and perinatal risks are highest remote from term.Study Design: Open-label, single arm safety and efficacy trial of rhAPC in consenting pregnant women with severe early-onset preeclampsia. Disease severity-matched rhAPC-naïve controls were identified from an existing database. An additional six women were recruited as biomarker controls.Main Outcome Measures: Primary safety outcome: incidence of peripartum bleeding; primary efficacy outcome: duration of pregnancy after enrolment.Results: Twelve (31.6%) of 38 eligible women consented; 3 did not receive the infusion due to staffing. Therefore, 9 women received rhAPC (24 μg/kg/hr for ≤96 h antenatally). No safety issues were identified. There was a marginal prolongation in eligibility-to-delivery intervals for women receiving rhAPC (Mantel-Cox p = 0.052; Gehan-Breslow-Wilcoxon p = 0.049). Compared with both the pre-infusion phase in the rhAPC-treated women themselves and with fullPIERS rhAPC-naïve women, rhAPC was associated with increased urine output during the infusion (6/9 vs 1/9 had urine output >100 mL/h during the infusion, Fisher's exact p = 0.003).Conclusions: These data support further investigation of APC in women with severe early-onset preeclampsia; recombinant and purified human APC is available. In addition, these data will inform the design and implementation of randomized controlled trials aiming to modify and/or moderate the proinflammatory and proacoagulant state of preeclampsia. [ABSTRACT FROM AUTHOR]

Over 20% of pregnancies involve medical difficulties that pose some threat to the health and well-being of the mother, her developing infant, or both. We report on the first comparison of the prevalence and incidence of maternal anxiety disorders (AD) in pregnancy and the postpartum, across levels of medical risk in pregnancy. Pregnant women ( N = 310) completed postnatal screening measures for anxiety. Women who scored at or above cutoff on one or more of the screening measures were administered a diagnostic interview ( n = 115) for AD. Pregnancies were classified into low, moderate, or high risk based on self-report and contact with high-risk maternity clinics. The incidence of AD in pregnancy was higher among women classified as experiencing a medically moderate or high-risk pregnancy, compared with women classified as experiencing a medically low-risk pregnancy. Across risk groups, there were no differences in AD prevalence or in the incidence of AD in the postpartum. Demographic characteristics and parity did not contribute meaningfully to outcomes. Pregnancies characterized by medical risks are associated with an increased likelihood of new onset AD. Women experiencing medically complex pregnancies should be screened for anxiety and offered appropriate treatment. [ABSTRACT FROM AUTHOR]

Background To determine if maternal characteristics measurable upon admission to hospital predict cesarean among low-risk spontaneously laboring nulliparous women. Methods We undertook a secondary analysis of data from a clinical trial of early labor support for nulliparous women carrying a singleton fetus in cephalic presentation at 37-41 weeks of gestation in British Columbia, Canada. Study participants did not have any discernible risk factors for cesarean at the onset of labor. We developed a prediction model using logistic regression from a sample of 1,302 participants. Internal validation of the model was accomplished by 10-fold cross validation, after which probability scores were calculated based on the mean logistic regression model. To determine the accuracy of our predictive model, we calculated the specificity and sensitivity and the area under the receiver operating curve. Results Advanced maternal age, shorter maternal height, greater gestational age, perception of labor lasting more than 24 hours, and mild or moderate contractions, less cervical dilation, and higher fetal station at time of hospital admission independently predicted cesarean. The C-statistic for the predictive model was 0.71 (0.64-0.75) and the sensitivity and specificity of the model were 0.80 (95% CI 0.76-0.84) and 0.48 (95% CI 0.44-0.52), respectively. Conclusions Among nulliparous women without apparent risk for cesarean at the time of hospital admission, cesarean delivery can be predicted with 70 percent accuracy using routinely collected information. Tailoring intrapartum care to promote vaginal birth according to a prediction model for cesarean risk deserves further study among apparently low risk women. [ABSTRACT FROM AUTHOR]

We evaluated a patient education pamphlet on vaginal birth after cesarean (VBAC). Focus groups with 17 women in 4 communities involved a 5-item knowledge pretest and question on intention to plan VBAC, reading the pamphlet, a knowledge posttest, and a moderated discussion. Forming a preference for birth after cesarean was characterized by (a) consolidating information from social sources, (b) seeking certainty in your next birth, and (c) questioning your ability to have a vaginal birth. Participants preferred vaginal birth, but all feared the uncertainty of labor. Knowledge scores increased for all participants, but intentions to plan a VBAC did not change. Our findings may encourage the development of interventions to reduce women's fear of vaginal birth. [ABSTRACT FROM AUTHOR]

Background: Home birth is available to women in Canada who meet eligibility requirements for low risk status after assessment by regulated midwives. While UK researchers have reported lower costs associated with planned home birth, there have been no published studies of the costs of home versus hospital birth in Canada. Methods: Costs for all women planning home birth with a regulated midwife in British Columbia, Canada were compared with those of all women who met eligibility requirements for home birth and were planning to deliver in hospital with a registered midwife, and with a sample of women of similar low risk status planning birth in the hospital with a physician. We calculated costs of physician service billings, midwifery fees, hospital in-patient costs, pharmaceuticals, home birth supplies, and transport. We compared costs among study groups using the Kruskall Wallis test for independent groups. Results: In the first 28 days postpartum, we report a $2,338 average savings per birth among women planning home birth compared to hospital birth with a midwife and $2,541 compared to hospital birth planned with a physician. In longer term outcomes, similar reductions were observed, with cost savings per birth at $1,683 compared to the planned hospital birth with a midwife, and $1,100 compared to the physician group during the first eight weeks postpartum. During the first year of life, costs for infants of mothers planning home birth were reduced overall. Cost savings compared to planned hospital births with a midwife were $810 and with a physician $1,146. Costs were similarly reduced when findings were stratified by parity. Conclusions: Planned home birth in British Columbia with a registered midwife compared to planned hospital birth is less expensive for our health care system up to 8 weeks postpartum and to one year of age for the infant. [ABSTRACT FROM AUTHOR]

Background Progress during early labour may impact subsequent labour trajectories. Women admitted to hospital in latent phase (<3 cm cervical dilation) labour have been shown to be at higher risk of obstetrical interventions. Methods We conducted a secondary analysis of data from a randomized controlled trial of 1247 healthy nulliparous women in spontaneous labour at term with a singleton fetus in cephalic presentation at seven hospitals in Southwestern British Columbia. We computed relative risks and their 95% confidence intervals to examine our primary outcome of cesarean section and secondary outcomes including obstetrical interventions and maternal and newborn outcomes according to women's perception of length of pre-hospital labour. Women were asked on admission to hospital how long they had been experiencing contractions prior to coming to hospital. Results Women indicating that they had been in labour for 24 hours or longer at the time of hospital admission were at elevated risk for cesarean birth, relative risk (RR) 1.40, (95% Confidence Intervals 1.15-1.72), admission with a cervical dilation of 3 cm or less, RR 1.21 (1.07-1.36), more obstetrical interventions including continuous electronic fetal monitoring RR 1.11 (1.03-1.20), augmentation of labour RR 1.33 (1.23-1.44), use of narcotic RR 1.21 (1.06-1.37) and epidural analgesia RR 1.18 (1.09-1.28). Adverse neonatal outcomes did not differ apart from a significant increase in meconium-stained amniotic fluid RR 1.60 (1.09-2.35). Conclusions A single question asked of women on presentation to hospital was an important predictor of cesarean birth and may have utility in identifying women who would benefit from close observation and more active management of labour. [ABSTRACT FROM AUTHOR]

To describe and evaluate recruitment techniques used to enroll 152 healthy pregnant women fewer than 15 weeks gestation into a prospective study of environmental chemical exposure during pregnancy. Posters, a website, online and print advertising, recruitment emails, media coverage, recruitment from clinic waiting rooms, networking within the pregnancy community and presenting a study booth at baby 'trade shows' were used to advertise the study. Participants had to meet a strict set of eligibility criteria, and were asked to donate two-second-trimester blood samples, complete two questionnaires, have samples of air, dust, lint and tap water collected from their homes, and donate a cord blood sample at delivery. Over 17 months, 171 women enrolled (49% of initial contacts, and 99% of all eligible women) and 152 women completed the study (89% retention). Total recruitment costs were approximately $400 Cdn per final participant. Posters, study booth presentations and online advertising generated the most inquiries about the study. Word of mouth, referral from another study and direct email were the most cost-effective strategies. Not surprisingly, the recruited study population was less ethnically diverse, more affluent and more educated than the background population of pregnant women in Vancouver. A combination of passive and active recruitment techniques were successful for recruiting healthy women in roughly the first trimester of pregnancy (<15 weeks gestation). While a convenience sample of women is suitable for our study questions, additional strategies may be required to recruit a more representative pregnant population in future studies. [ABSTRACT FROM AUTHOR]

We examined the association between rural residence and birth outcomes in older mothers, the effect of parity on this association, and the trend in adverse birth outcomes in relation to the distance to the nearest hospital with cesarean-section capacity. A population-based retrospective cohort study, including all singleton births to 35+ year-old women in British Columbia (Canada), 1999-2003. We compared birth outcomes in rural versus urban areas, and between 3 distance categories to a hospital (<50, 50-150, >150 km). Outcomes included labor induction, cesarean section, stillbirth, perinatal death, preterm birth (<37 weeks), small-for-gestational-age, large-for-gestational-age, and neonatal intensive care unit admission. We used multivariate regression to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Among the 29,698 subjects, 11.5% lived in rural areas; 5% lived within 50-150 km; and 1.1% lived >150 km from a hospital. Rural women were at lower risk of primary and repeat cesarean section (OR = 0.9, CI: 0.9-1.0; OR = 0.7, CI: 0.6-0.9) and small-for-gestational-age (OR = 0.8, CI: 0.7-0.9) births; they were at increased risk for perinatal death (OR = 1.5, CI: 1.1-2.1) and large-for-gestational-age (OR = 1.1, CI: 1.1-1.2) births. The association was stronger among multiparous versus primiparous women. No differences in emergency cesarean section, preterm birth, or neonatal intensive care admission were found, regardless of parity. Perinatal mortality increased with distance from hospital; OR = 1.5 (CI: 1.1-2.1) per distance category. Older women in rural versus urban areas had a lower rate of cesarean section and increased risk of perinatal death. The risk of perinatal death increased with the distance to hospital. Further studies need to evaluate the contribution of underlying perinatal risks, access to care, and decision making regarding referral and transport. [ABSTRACT FROM AUTHOR]

Background: Studies of planned home births attended by registered midwives have been limited by incomplete data, nonrepresentative sampling, inadequate statistical power and the inability to exclude unplanned home births. We compared the outcomes of planned home births attended by midwives with those of planned hospital births attended by midwives or physicians. Methods: We included all planned home births attended by registered midwives from Jan. 1, 2000, to Dec. 31, 2004, in British Columbia, Canada (n = 2889), and all planned hospital births meeting the eligibility requirements for home birth that were attended by the same cohort of midwives (n = 4752). We also included a matched sample of physician-attended planned hospital births (n = 5331). The primary outcome measure was perinatal mortality; secondary outcomes were obstetric interventions and adverse maternal and neonatal outcomes. Results: The rate of perinatal death per 1000 births was 0.35 (95% confidence interval [CI] 0.00-1.03) in the group of planned home births; the rate in the group of planned hospital births was 0.57 (95% CI 0.00-1.43) among women attended by a midwife and 0.64 (95% CI 0.00-1.56) among those attended by a physician. Women in the planned home-birth group were significantly less likely than those who planned a midwife-attended hospital birth to have obstetric interventions (e.g., electronic fetal monitoring, relative risk [RR] 0.32, 95% CI 0.29-0.36; assisted vaginal delivery, RR 0.41, 95% 0.33-0.52) or adverse maternal outcomes (e.g., third- or fourth-degree perineal tear, RR 0.41, 95% CI 0.28-0.59; postpartum hemorrhage, RR 0.62, 95% CI 0.49-0.77). The findings were similar in the comparison with physician-assisted hospital births. Newborns in the home-birth group were less likely than those in the midwife- attended hospital-birth group to require resuscitation at birth (RR 0.23, 95% CI 0.14-0.37) or oxygen therapy beyond 24 hours (RR 0.37, 95% CI 0.24-0.59). The findings were similar in the comparison with newborns in the physician-assisted hospital births; in addition, newborns in the home-birth group were less likely to have meconium aspiration (RR 0.45, 95% CI 0.21-0.93) and more likely to be admitted to hospital or readmitted if born in hospital (RR 1.39, 95% CI 1.09-1.85). Interpretation: Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician. [ABSTRACT FROM AUTHOR]

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Objectives : Attempts to introduce assessment for exposure to domestic violence in health care settings have met with limited success, in spite of widespread knowledge of the prevalence of spousal abuse and its implications for women's health. We assessed the utility of Rogers' model of institutional change for the implementation of a universal screening program for domestic violence in postpartum clinical settings. Methods : We adapted Rogers' innovation–diffusion model to develop and implement a protocol for domestic violence assessment among 300 nurses working in two hospitals that together provide obstetrical care to the City of Vancouver, British Columbia, Canada. Our education sessions introduced new knowledge and addressed attitudes and beliefs. They were followed by “hands-on” demonstration and supervision of assessments. Our “Let's Talk” visual aids program added visibility to our initiative and provided cues as to how to undertake screening and response. Screening rates were monitored along with a process evaluation based on anecdotal reporting by nursing staff. Results : Following the initiation of educational sessions and supervision of assessment, the screening rate was 42%. Within 6 months, the screening rate had climbed to 60% and was sustained at that level. Major barriers to screening include difficulty in finding the opportunity to screen in privacy and overcoming language barriers. Conclusions : Application of Rogers' principles of diffusion of innovation in the implementation of a universal program for a domestic violence in two obstetrical care settings resulted in a screening rate of 60% which has been sustained for the first 18 months of the program. [ABSTRACT FROM AUTHOR]

Background: The choice to give birth at home with a regulated midwife in attendance became available to expectant women in British Columbia in 1998. The purpose of this study was to evaluate the safety of home birth by comparing perinatal outcomes for planned home births attended by regulated midwives with those for planned hospital births. Methods: We compared the outcomes of 862 planned home births attended by midwives with those of planned hospital births attended by either midwives (n = 571) or physicians (n = 743). Comparison subjects who were similar in their obstetric risk status were selected from hospitals in which the midwives who were conducting the home births had hospital privileges. Our study population included all home births that occurred between Jan. 1, 1998, and Dec. 31, 1999. Results: Women who gave birth at home attended by a midwife had fewer procedures during labour compared with women who gave birth in hospital attended by a physician. After adjustment for maternal age, lone parent status, income quintile, use of any versus no substances and parity, women in the home birth group were less likely to have epidural analgesia (odds ratio 0.20, 95% confidence interval [CI] 0.14-0.27), be induced, have their labours augmented with oxytocin or prostaglandins, or have an episiotomy. Comparison of home births with hospital births attended by a midwife showed very similar and equally significant differences. The adjusted odds ratio for cesarean section in the home birth group compared with physician-attended hospital births was 0.3 (95% CI 0.22-0.43). Rates of perinatal mortality, 5-minute Apgar scores, meconium aspiration syndrome or need for transfer to a different hospital for specialized newborn care were very similar for the home birth group and for births in hospital attended by a physician. The adjusted odds ratio for Apgar scores lower than 7 at 5 minutes in the home birth group compared with physician-attended hospital births with physician... [ABSTRACT FROM AUTHOR]

Background: Single room maternity care is the provision of intrapartum and postpartum care in a single room. It promotes a philosophy of family centered care in which one nurse cares for the family consistently throughout the intrapartum and postpartum periods. At B.C. Women's Hospital, a tertiary level obstetric teaching hospital in Vancouver, British Columbia, a seven-bed, single room maternity care unit was developed and opened as a demonstration project. As part of the evaluation of this unit, client satisfaction was compared between women enrolled in single room maternity care and those in a traditional setting. Method: The study group included 205 women who were admitted to the single room maternity care unit after meeting the low-risk criteria. Their responses on a satisfaction survey were compared with those of a historical comparison group of 221 women meeting the same eligibility criteria who were identified through chart audits 3 months before the single room maternity care unit was opened. A second, concurrent comparison group comprised 104 women who also met eligibility criteria. Results: Study group women were more satisfied than comparison groups in all areas evaluated, including provision of information and support, physical environment, nursing care, patient education, assistance with infant feeding, respect for privacy, and preparation for discharge. Conclusions: Single room maternity care was associated with a significant improvement in client satisfaction because of many factors, including the physical setting itself, avoidance of transfers, and improved continuity of nursing care. [ABSTRACT FROM AUTHOR]

Background: Unwanted, intrusive thoughts of harm-related to the infant are reported by the vast majority of new mothers, with half of all new mothers reporting unwanted, intrusive thoughts of harming their infant on purpose. Thoughts of intentional harm, in particular, are distressing to women, their partners and the people who care for them. While maternal, unwanted and intrusive thoughts of infant-related harm are known to be associated with obsessive compulsive disorder (OCD) and depression, preliminary evidence suggests that they are not associated with an increased risk of harm to infants. Perinatal care providers and policy makers, as well as new mothers and their partners require evidence-based information in order to respond appropriately to these types of thoughts. The purpose of this research is to address important gaps regarding the (a) prevalence and characteristics of intrusive, unwanted thoughts of baby-related harm, (b) their association (or lack thereof) with child abuse, and (c) the prevalence and course of obsessive-compulsive disorder and depression in the perinatal period. Methods: Participant were 763 English-speaking women and recruited during pregnancy. In this province-wide study in British Columbia, participants were recruited proportionally from hospitals, city centers and rural communities between January 23, 2014 and September 09, 2016. Participants were administered online questionnaires and diagnostic interviews over the phone at 33-weeks gestation, 7-weeks postpartum and 4-months postpartum. The study assessed intrusive and unwanted thoughts of harm related to the infant, obsessive-compulsive disorder (OCD) and major depressive episode (MDE) disorders and symptomatology, sleep, medical outcomes, parenting attitudes, and infant abuse. Discussion: There is a scarcity of literature concerning maternal unwanted, intrusive, postpartum thoughts of infant-related harm and their relationship to child harming behaviors, OCD and depression. This longitudinal cohort study was designed to build on the existing research base to ensure that policy developers, child protection workers and health-care providers have the guidance they need to respond appropriately to the disclosure of infant-related harm thoughts. Thus, its main goals will be to investigate whether intrusive postpartum thoughts of infant-related harm are a risk factor for child abuse or the development of OCD. [ABSTRACT FROM AUTHOR]

Background: Rates of gestational diabetes are reported to be increasing in many jurisdictions, but the reasons for this are poorly understood. We sought to evaluate the relative contribution of screening practices for gestational diabetes (including completion and methods of screening) and population characteristics to risk of gestational diabetes in British Columbia, Canada, from 2005 to 2019., Methods: We used a population-based cohort from a provincial registry of perinatal data, linked to laboratory billing records. We used data on screening completion, screening method (1-step 75-g glucose test or 2-step approach of 50-g glucose screening test, followed by a diagnostic test for patients who screen positive) and demographic risk factors. We modelled predicted annual risk for gestational diabetes, sequentially adjusted for screening completion, screening method and risk factors., Results: We included 551 457 pregnancies in the study cohort. The incidence of gestational diabetes more than doubled over the study period, from 7.2% in 2005 to 14.7% in 2019. Screening completion increased from 87.2% in 2005 to 95.5% in 2019. Use of 1-step screening methods increased from 0.0% in 2005 to 39.5% in 2019 among those who were screened. Unadjusted models estimated a 2.04 (95% confidence interval [CI] 1.94-2.13) increased risk of gestational diabetes in 2019 (v. 2005). This increase was 1.89 (95% CI 1.81-1.98) after accounting for the rise in screening completion and 1.34 (95% CI 1.28-1.40) after accounting for changes in screening methods. Further accounting for demographic risk factors (e.g., age, body mass index, prenatal care) had a small impact (increase of 1.25, 95% CI 1.19-1.31)., Interpretation: Most of the observed increase in the incidence of gestational diabetes was attributable to changes in screening practices (primarily changes in screening methods) rather than changing population factors. Our findings highlight the importance of understanding variation in screening practices when monitoring incidence rates for gestational diabetes., Competing Interests: Competing interests: Michael Law has consulted for Health Canada and iTAD, and has provided expert witness testimony for the Federation of Post-Secondary Educators. No other competing interests were declared., (© 2023 CMA Impact Inc. or its licensors.)

Objectives: To examine trends in the frequency and method (one-step vs. two-step) of gestational diabetes mellitus (GDM) screening in British Columbia (BC), Canada, across subgroups of pregnant individuals in the context of changing local and national clinical practice guidelines., Methods: We conducted a retrospective cohort study using de-identified, linked perinatal and laboratory billing data. We included all pregnancies delivered in BC after 28 weeks gestation, with screening dates between June 2004 and May 2019. We calculated the prevalence of each screening method with 95% CI overall and over time, and we examined screening practices in subgroups and different geographic regions. In October 2010, BC began recommending a one-step method; therefore, we examined time periods relative to this and other Canadian guideline changes., Results: Screening completion increased over the study period, from 88% in 2004 to 96% in 2019. After a guideline change in 2010, use of one-step screening increased sharply from 2.0% (95% CI 1.9-2.0) to 45.2% (95% CI 44.9-45.6). Following the 2013 Diabetes Canada guideline change, one-step screening decreased to 42.8% (95% CI 42.5-43.1). Of those receiving one-step screening, 18% were diagnosed with GDM compared to 9% with two-step screening. Use of one-step screening was higher in pregnant people with risk factors and in larger urban centres., Conclusion: GDM screening in BC demonstrated higher use of one-step screening among people with risk factors; however, there were strong regional disparities and considerable variation in screening practices over time and across subgroups., (Copyright © 2023 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Background: Prevalence statistics for pregnancy complications identified through screening such as gestational diabetes usually assume universal screening. However, rates of screening completion in pregnancy are not available in many birth registries or hospital databases. We validated screening-test completion by comparing public insurance laboratory and radiology billing records with medical records at three hospitals in British Columbia, Canada., Methods: We abstracted a random sample of 140 delivery medical records (2014-2019), and successfully linked 127 to valid provincial insurance billings and maternal-newborn registry data. We compared billing records for gestational diabetes screening, any ultrasound before 14 weeks gestational age, and Group B streptococcus screening during each pregnancy to the gold standard of medical records by calculating sensitivity and specificity, positive predictive value, negative predictive value, and prevalence with 95% confidence intervals (CIs)., Results: Gestational diabetes screening (screened vs. unscreened) in billing records had a high sensitivity (98% [95% CI = 93, 100]) and specificity (>99% [95% CI = 86, 100]). The use of specific glucose screening approaches (two-step vs. one-step) were also well characterized by billing data. Other tests showed high sensitivity (ultrasound 97% [95% CI = 92, 99]; Group B streptococcus 96% [95% CI = 89, 99]) but lower negative predictive values (ultrasound 64% [95% CI = 33, 99]; Group B streptococcus 70% [95% CI = 40, 89]). Lower negative predictive values were due to the high prevalence of these screening tests in our sample., Conclusions: Laboratory and radiology insurance billing codes accurately identified those who completed routine antenatal screening tests with relatively low false-positive rates., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Compared with children who are HIV-unexposed and uninfected (CHUU), children who are HIV-exposed and uninfected (CHEU) experience more clinical complications. We investigated hospitalizations among CHEU by antenatal antiretroviral therapy (ART) exposure, in British Columbia, Canada., Methods: This retrospective controlled cohort study used administrative health data from 1990 to 2012. CHEU and CHUU were matched 1:3 for age, sex and maternal geographical area of residence. We determined adjusted odds ratios (aORs) via conditional logistic regression, adjusting for maternal risk factors., Results: A total of 446 CHEU and 1333 CHUU were included. Compared with CHUU, more CHEU experienced one or more lifetime hospitalization (47.3% vs. 29.8%), one or more neonatal hospitalization (40.4% vs. 27.6%), and any intensive care unit admission (28.5% vs. 9.2%). In adjusted analyses, CHEU experienced higher odds of any lifetime hospitalization (aOR 2.30, 95% confidence interval 1.81-2.91) and neonatal hospitalization (aOR 2.14, 95% confidence interval 1.68-2.73), compared with CHUU. There was, however, no difference in infection-related hospitalizations (9.0% vs. 7.5%), which were primarily respiratory tract infections among both CHEU and CHUU. CHEU whose mothers-initiated ART preconception showed lower odds of infection-related hospitalizations than children whose mothers initiated ART during pregnancy or received no ART., Conclusions: CHEU experienced increased odds of hospitalization relative to CHUU. A substantial number of CHEU hospitalizations occurred within the neonatal period and were ICU admissions. Initiating ART preconception may reduce the risk of infection-related hospitalizations. These findings reinforce the benefit of ART in pregnancy and the need for ongoing pediatric care to reduce hospitalizations., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: During the perinatal period, women are at an increased risk for the onset/exacerbation of obsessive-compulsive disorder (OCD) and may experience perinatal-specific obsessions and/or compulsions. Past research has provided preliminary findings regarding the prevalence of OCD in the perinatal period but has often reported limited metrics and ignored perinatal specific symptoms. This research aimed to assess the prevalence and incidence of maternal OCD between the third trimester in pregnancy and 6 months postpartum., Methods: An unselected sample of 763 English-speaking pregnant women and new mothers participated in a longitudinal, province-wide study between their third trimester in pregnancy and 9 months postpartum. They completed 3 online questionnaires and interviews (data collected between February 9, 2014, and February 14, 2017) and were administered a diagnostic interview to determine OCD status based on DSM-5 diagnostic criteria., Results: A weighted prenatal period prevalence of 7.8% and a postpartum period prevalence of 16.9% were found. The average, prenatal, point prevalence estimate was 2.9%, and the average, postpartum, point prevalence estimate was 7.0%. Point prevalence gradually increased over the course of pregnancy and the early postpartum, attaining a peak of close to 9% at approximately 8 weeks postpartum, with a gradual decline thereafter. The cumulative incidence of new OCD diagnoses was estimated at 9% by 6 months postpartum., Conclusions: Our study suggests that when women are encouraged to report their perinatal-specific symptoms, and current diagnostic criteria are applied, estimates for perinatal OCD may be higher than previously believed., (© Copyright 2021 Physicians Postgraduate Press, Inc.)

Background: Infants HIV-exposed and uninfected (IHEU) who are born to women living with HIV are at an increased risk of preterm birth (PTB). Antenatal exposure to certain maternal antiretroviral therapy (ART) regimens has been associated with PTB, although existing studies in this domain are limited and report discordant findings. We determined odds of PTB among IHEU by antenatal ART regimens and timing of exposure, adjusting for maternal risk factors., Methods: We retrospectively studied IHEU born in British Columbia (BC), Canada between 1990 and 2012 utilizing provincial health administrative databases. We included data from a control group of infants HIV-unexposed and uninfected (IHUU) matched ~3:1 for each IHEU on age, sex and geocode., Results: A total of 411 IHEU and 1224 IHUU were included in univariable analysis. PTB was more frequent among IHEU (20%) compared with IHUU (7%). IHEU were more often antenatally exposed to alcohol, tobacco, as well as prescription, nonprescription, and illicit drugs (IHEU: 36%, 8% and 35%; vs. IHUU: 3%, 1% and 9%, respectively). After adjusting for maternal substance use and smoking exposure, IHEU remained at increased odds of PTB [adjusted odds ratio (aOR) (95% CI): 2.66; (1.73, 4.08)] compared with matched IHUU controls. ART-exposed IHEU (excluding those with NRTIs only ART) had lower adjusted odds of PTB compared with IHEU with no maternal ART exposure, regardless of regimen [aOR range: 0.16-0.29 (0.02-0.95)]. Odds of PTB between IHEU exposed to ART from conception compared with IHEU exposed to ART postconception did not differ [aOR: 0.91 (0.47, 1.76)]; however, both groups experienced lower odds of PTB compared with IHEU with no maternal ART [preconception: aOR: 0.28 (0.08, 0.89); postconception: aOR 0.30 (0.11, 0.83)]., Conclusions: BC IHEU were over twice as likely to be born preterm compared with demographically matched controls. Maternal substance use in pregnancy modulated this risk; however, we found no adverse associations of PTB with exposure to antenatal ART., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Administrative data are frequently used to identify Autism Spectrum Disorder (ASD) cases in epidemiological studies. However, validation studies on this mode of case ascertainment have lacked access to high-quality clinical diagnostic data and have not followed published reporting guidelines. We report on the diagnostic accuracy of using readily available health administrative data for pediatric ASD case ascertainment. The validation cohort included almost all the ASD-positive children born in British Columbia, Canada from April 1, 2000 to December 31, 2009 and consisted of 8,670 children in total. 4,079 ASD-positive and 2,787 ASD-negative children were identified using Autism Diagnostic Observation Schedule (ADOS) and Autism Diagnostic Interview-Revised (ADI-R) assessments done through the British Columbia Autism Assessment Network (BCAAN). An additional 1,804 ADOS/ADI-R assessed ASD-positive children were identified using Ministry of Education records. This prospectively collected clinical data (the diagnostic gold standard) was then linked to each child's physician billing and hospital discharge data. The diagnostic accuracy of 11 algorithms that used the administrative data to assign ASD case status was assessed. For all algorithms, high positive predictive values (PPVs) were observed alongside low values for other measures of diagnostic accuracy illustrating that PPVs alone are not an adequate measure of diagnostic accuracy. We show that British Columbia's health administrative data cannot reliably be used to discriminate between children with ASD and children with other developmental disorders. Utilizing these data may result in misclassification bias. Methodologically sound, region-specific validation studies are needed to support the use of administrative data for ASD case ascertainment. Autism Res 2020, 13: 456-463. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Health administrative data are frequently used to identify Autism Spectrum Disorder (ASD) cases for research purposes. However, previous validation studies on this sort of case identification have lacked access to high-quality clinical diagnostic data and have not followed published reporting guidelines. We show that British Columbia's health administrative data cannot reliably be used to discriminate between children with ASD and children with other developmental disorders., (© 2019 International Society for Autism Research, Wiley Periodicals, Inc.)

Background: During the transition between prison and community, people are at greatly increased risk for adverse health outcomes. This study describes a peer health mentoring program that supports women in the first 3 days after their release from a provincial correctional facility in British Columbia., Methods: We used a participatory health research framework to develop multimethod processes to describe the Unlocking the Gates Peer Health Mentoring Program. Mentors are women with incarceration experience. Between 2013 and 2018, women released from Alouette Correctional Centre for Women were invited to access the program. All program clients were invited to participate in the surveys and interviews. We analyzed survey and interview data using descriptive analysis for quantitative data and content analysis for qualitative data., Results: There were 346 program contacts from 340 women over the study period. For every contact, a telephone interview was conducted. Among the 346 contacts, 173 women met their mentor, of whom 172 (99.4%) completed the intake and consent forms. A total of 105 women (61.0%) completed a program activity feedback survey at the end of the mentoring period. Women identified a range of needed supports during the transition from prison to community, including access to clothing, social assistance, housing and health care. Participants described a mix of emotions surrounding release, including excitement, anxiety, hope, and a wish for understanding and support. Within 3 days of release, 49 participants (46.7%) had accessed a family physician, and 89 (84.8%) had accessed at least 1 community resource. Ninety-eight participants (93.3%) reported that their mentor assisted them in accessing community resources., Interpretation: Peer health mentoring provides valuable, multifaceted support in helping women to navigate health and social services and to meet their basic needs. Strengthening health supports during the transition from prison to community is critical to promoting the health and well-being of women leaving prison., Competing Interests: Competing interests: Ruth Elwood Martin reports grants from the First Nations Health Authority during the conduct of the study. No other competing interests were declared., (Copyright 2020, Joule Inc. or its licensors.)

Objective: Our aim was to investigate if antenatal midwifery care was associated with lower odds of small-for-gestational-age (SGA) birth, preterm birth (PTB) or low birth weight (LBW) compared with general practitioner (GP) or obstetrician (OB) models of care for women of low socioeconomic position., Setting: This population-level, retrospective cohort study used province-wide maternity, medical billing and demographic data from British Columbia, Canada., Participants: Our study included 57 872 pregnant women, with low socioeconomic position, who: were residents of British Columbia, Canada, carried a singleton fetus, had low to moderate medical/obstetric risk, delivered between 2005 and 2012 and received medical insurance premium assistance., Primary and Secondary Outcome Measures: We report rates, adjusted ORs (aOR), and 95% CIs for the primary outcome, SGA birth (

Objective: This study sought to assess change in knowledge and preference for epidural use associated with use of an information pamphlet and to explore women's decision-making and information needs regarding pain relief in labour., Methods: Six focus groups with women who were pregnant or had given birth during the past 12 months were conducted in three northern communities in British Columbia. Following completion of a 10-item knowledge pretest, women were randomly assigned to read either a short version or a detailed version of the pamphlet and then complete a post-test. After reading the alternate pamphlet they participated in a moderated discussion. Pretest and post-test knowledge scores were compared, and a thematic analysis of focus group data was conducted., Results: Knowledge scores increased (2.12 points out of a possible total of 10; standard deviation 2.38; 95% CI 1.38 to 2.87). There was no difference in knowledge change or epidural preferences according to which version participants read first. Women preferred the detailed version and indicated that its information was more balanced. Four themes related to decision-making and information needs arose from the focus groups: making an informed choice, being open-minded, wanting comprehensive information, and experiencing pressure to have/not have an epidural., Conclusion: An illustrated information pamphlet can significantly increase women's knowledge of benefits and risks of epidural analgesia, but it is not associated with change of preference. Women prefer to receive comprehensive information prenatally to support informed choices in labour., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the incidence in British Columbia of severe morbidity in neonates delivered by Caesarean section for non-reassuring fetal status, and to examine the accuracy of Apgar score and umbilical cord gas values in predicting severe neonatal morbidity., Methods: We assessed rates of hypoxic ischemic encephalopathy, NICU admission, and ventilator days, individually and as a composite outcome with neonatal death, among a total of 8466 term singletons delivered by Caesarean section for non-reassuring fetal status between January 1, 2007, and December 31, 2011. We calculated the predictive accuracy of Apgar scores and umbilical cord blood gas values using the area under the receiver operating characteristic (ROC) curve and the sensitivity and specificity for each outcome., Results: The incidence of Apgar score at one minute < 4 was 8.0%, and for Apgar score at five minutes < 4 it was 0.6%. The incidence of umbilical cord pH < 7.10 was 6.5%, and for base-excess < -12 it was 2.9%. Apgar score at one minute < 7 had the greatest predictive accuracy for the composite outcome (81% for both sensitivity and specificity). The area under the ROC curve for Apgar score at one minute and at five minutes, umbilical cord pH, and base-excess was 0.87, 0.86, 0.76, and 0.78, respectively., Conclusion: The incidence of abnormal Apgar score and abnormal umbilical cord gas values is very low among neonates in British Columbia delivered by Caesarean section for non-reassuring fetal status. Apgar score at one minute < 7 is a good predictor of severe neonatal morbidity. Electronic fetal monitoring remains a non-specific method for detection of fetal compromise in the intrapartum period.

Background: Although research has established the profound effects that intimate partner abuse can have on postpartum mental health, little is known regarding how this association may change as a function of the timing and type of abuse. This study examined associations of psychological, physical and sexual abuse experienced as adults before and during pregnancy with symptoms of postpartum mental health problems in a non-clinical sample of women., Methods: English-speaking mothers aged 18 years and older in the metropolitan area of a large, Western Canadian city were recruited to participate in a study of women's health after pregnancy. The study was advertised in hospitals, local newspapers, community venues, and relevant websites. One-hundred women completed standardized, self-report questionnaires during semi-structured interviews conducted by female research assistants at approximately 2 months postpartum. In addition to questions about their general health and well-being, participants answered questions about their experiences of intimate partner abuse and about their mental health during the postpartum period., Results: Almost two-thirds (61.0%) of women reported postpartum mental health symptoms above normal levels, with 47.0% reporting symptoms at moderate or higher levels. The majority reported some form of intimate partner abuse before pregnancy (84.0%) and more than two-thirds (70.0%), during pregnancy; however, the abuse was typically minor in nature. Multivariate models revealed that women who experienced intimate partner abuse-whether before or during pregnancy-reported higher levels of postpartum mental health problems; however, associations differed as a function of the timing and type of abuse, as well as specific mental health symptoms. Multivariate models also showed that as the number of types of intimate partner abuse experienced increased, so did the negative effects on postpartum mental health., Conclusions: Results of this study provide further evidence that intimate partner abuse is a risk factor for postpartum mental health problems. They also underscore the complex risks and needs associated with intimate partner abuse among postpartum women and support the use of integrated approaches to treating postpartum mental health problems. Future efforts should focus on the extent to which strategies designed to reduce intimate partner abuse also improve postpartum mental health and vice versus.

Objective: to describe the development and psychometric properties of the Early Labour Experiences Questionnaire (ELEQ)., Design: randomized controlled trial., Setting: hospitals serving obstetric populations in metropolitan and suburban Vancouver, British Columbia, Canada., Participants: 423 healthy nulliparous women in labour at term with uncomplicated pregnancies., Intervention: women were randomized to telephone support (n=241) or home visit (n=182) study groups and completed the ELEQ during the postpartum phase of their hospital stay., Measurement: the ELEQ contains 26 self-report items, rated on a 5-point scale, that measure women's affective experience of early labour (14 items), perceptions of nursing care (12 items), whether they would recommend this type of early labour care to a friend (1 item), and whether they believed they went to the hospital at the right time (1 item). An exploratory factor analysis was conducted to determine whether the items grouped together into subscales. The structural reliability of the extracted subscales and total scores were evaluated using a number of coefficients. To test criterion validity, we compared ELEQ item, subscale and total scores between the study groups., Findings: item and total scores showed significant variability. Factor analysis yielded three subscales: Emotional Well-Being, Emotional Distress and Perceptions of Nursing Care. The subscale and total scores showed good internal consistency and item homogeneity, and were interrelated in the expected direction. Items evidenced strong associations with the subscale and total scores. Comparisons between study groups offered some support for criterion validity., Key Conclusions: pending further validation, the ELEQ can contribute to the assessment of women's experiences with different aspects of maternity care, evaluation of the quality of maternity care, and improvement of maternity services., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: to compare experiences with early labour assessment and support at home vs. by telephone., Design: a randomised controlled trial of nurse home visits vs. telephone support for assessment and support of women in early labour., Setting: hospitals serving obstetrical populations in metropolitan and suburban Vancouver, British Columbia, Canada., Participants: healthy nulliparous women in labour at term with uncomplicated pregnancies participating in the third and fourth year of the trial., Intervention: women were randomised to receive early labour assessment and support at home (n=241) and or to receive assessment and support by telephone (n=182)., Measurement: the Early Labour Experience Questionnaire (ELEQ), a 26-item self-administered questionnaire that measures women's experience with early labour care across three domains: emotional well-being, emotional distress and perceptions of nursing care., Findings: women who received home visits rated their early labour experience more positively overall compared to women who received telephone support (103.14 ± 12.45 vs. 99.67 ± 13.11, p<.01)including perceptions of nursing care that they received (38.64 ± 2.90 vs. 36.82 ± 4.09, p<.001). However, women's affective experiences did not differ., Key Conclusions: early labour nursing care provided at home is associated with a more positive experience of early labour compared to telephone support., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: The number of physicians providing maternity care in Canada is decreasing, and the rate of cesarean delivery is increasing. We evaluated the effect on perinatal outcomes of an interdisciplinary program designed to promote physiologic birth and encourage active involvement of women and their families in maternity care., Methods: We conducted a retrospective cohort study involving 1238 women who attended the South Community Birth Program in Vancouver, Canada, from April 2004 to October 2010. The program offers comprehensive, collaborative, interdisciplinary care from family physicians, midwives, community health nurses and doulas to a multiethnic, low-income population. A comparison group, matched for neighbourhood of residence, maternal age, parity and gestational age at delivery, comprised 1238 women receiving standard care in community-based family physician, obstetrician and midwife practices. The primary outcome was the proportion of women who underwent cesarean delivery., Results: Compared with women receiving standard care, those in the birth program were more likely to be delivered by a midwife (41.9% v. 7.4%, p < 0.001) instead of an obstetrician (35.5% v. 69.6%, p < 0.001). The program participants were less likely than the matched controls to undergo cesarean delivery (relative risk [RR] 0.76, 95% confidence interval [CI] 0.68-0.84) and, among those with a previous cesarean delivery, more likely to plan a vaginal birth (RR 3.22, 95% CI 2.25-4.62). Length of stay in hospital was shorter in the program group for both the mothers (mean ± standard deviation 50.6 ± 47.1 v. 72.7 ± 66.7 h, p < 0.001) and the newborns (47.5 ± 92.6 v. 70.6 ± 126.7 h, p < 0.001). Women in the birth program were more likely than the matched controls to be breastfeeding exclusively at discharge (RR 2.10, 95% CI 1.85-2.39)., Interpretation: Women attending a collaborative program of interdisciplinary maternity care were less likely to have a cesarean delivery, had shorter hospital stays on average and were more likely to breastfeed exclusively than women receiving standard care.

Objectives: Birth weight distributions differ according to the ethnic origin of the mother. We aimed to determine whether using ethnicity-specific growth distributions would identify newborns at risk for adverse infant outcomes associated with small for gestational age (SGA) birth better than population-based distributions., Methods: We examined 2647 singletons born to healthy non-smoking mothers at British Columbia Women's Hospital at 37 to 41 completed weeks' gestation. We compared the ability of ethnicity-specific growth distributions and population-based distributions to predict which infants were at increased risk of adverse outcomes associated with SGA, as well as extended length of stay in hospital, using crude and adjusted odds ratios., Results: The ethnicity-specific growth distributions were associated with an increased risk of adverse infant outcomes while the population-based distributions were not (adjusted odds ratio [aOR] 1.49 [95% CI 0.82 to 2.70] vs. aOR 0.88 [95% CI 0.48 to 1.64]). While both distributions predicted extended length of stay in hospital, this likely reflects clinicians' use of the population-based distribution to identify SGA infants., Conclusions: The use of ethnicity-specific growth distributions will likely improve our ability to differentiate between babies who are pathologically small and those who are constitutionally small, and prevent misclassification of constitutionally small but healthy newborns born to mothers of Chinese or South Asian descent as SGA.

Background: The major aim of this study was to investigate whether maternal risk factors associated with socioeconomic status and small for gestational age (SGA) might be viable targets of interventions to reduce differential risk of SGA by socioeconomic status (socioeconomic SGA inequality) in the metropolitan area of Vancouver, Canada., Methods: This study included 59,039 live, singleton births in the Vancouver Census Metropolitan Area (Vancouver) from January 1, 2006 to September 17, 2009. To identify an indicator of socioeconomic SGA inequality, we used hierarchical logistic regression to model SGA by area-level variables from the Canadian census. We then modelled SGA by area-level average income plus established maternal risk factors for SGA and calculated population attributable SGA risk percentages (PAR%) for each variable. Associations of maternal risk factors for SGA with average income were investigated to identify those that might contribute to SGA inequality. Finally, we estimated crude reductions in the percentage and absolute differences in SGA risks between highest and lowest average income quintiles that would result if interventions on maternal risk factors successfully equalized them across income levels or eliminated them altogether., Results: Average income produced the most linear and statistically significant indicator of socioeconomic SGA inequality with 8.9% prevalence of SGA in the lowest income quintile compared to 5.6% in the highest. The adjusted PAR% of SGA for variables were: bottom four quintiles of height (51%), first birth (32%), bottom four quintiles of average income (14%), oligohydramnios (7%), underweight or hypertension, (6% each), smoking (3%) and placental disorder (1%). Shorter height, underweight and smoking during pregnancy had higher prevalence in lower income groups. Crude models assuming equalization of risk factors across income levels or elimination altogether indicated little potential change in relative socioeconomic SGA inequality and reduction in absolute SGA inequality for shorter height only., Conclusions: Our findings regarding maternal height may indicate trans-generational aetiology for socioeconomic SGA inequalities and/or that adult height influences social mobility. Conditions affecting foetal and childhood growth might be viable targets to reduce absolute socioeconomic SGA inequality in future generations, but more research is needed to determine whether such an approach is appropriate.

Objective: To examine regional variations in rates of primary cesarean delivery and assisted vaginal delivery in the population of British Columbia, while adjusting for the maternal characteristics and conditions that increase the likelihood of operative delivery., Methods: Using data from the British Columbia Perinatal Database Registry, we studied all deliveries in British Columbia between 2004 and 2007, excluding women who had a previous cesarean delivery (n=116,839). Our primary outcome of interest was mode of delivery, further defined as delivery by cesarean or assisted vaginal delivery. We calculated crude and risk-adjusted rates of primary cesarean delivery and assisted vaginal delivery across British Columbia's 16 Health Service Delivery Areas and examined cesarean delivery rates by indication for the procedure., Results: Crude primary cesarean delivery and assisted vaginal delivery rates varied markedly across the Health Service Delivery Areas ranging from 16.1 to 27.5 per 100 deliveries, and from 8.6 to 18.6 per 100 deliveries, respectively. The most common indication for cesarean delivery was dystocia, which accounted for 30.0% of all cesarean deliveries and varied more than fivefold across regions. After controlling for maternal characteristics and conditions known to increase the likelihood of cesarean delivery and assisted vaginal delivery, adjusted cesarean delivery rates varied twofold, ranging from 14.7 to 27.6 per 100 deliveries, while adjusted assisted vaginal delivery rates varied by more than twofold, ranging from 6.5 to 15.3 per 100 deliveries., Conclusion: Our results illustrate substantial regional variation in the use of cesarean delivery that cannot be explained by patient illness or preferences. This variation likely reflects differences in practitioners' approaches to medical decision-making., Level of Evidence: II.

Background: Home birth remains a contentious issue in North America. Professional regulatory bodies are in conflict about the safety of home birth as an option for healthy women. The voices of women have largely been ignored in this debate. The purpose of this study is to report on the experiences of 559 women who had a planned home birth over a 2-year period in British Columbia, Canada., Methods: We asked all women in the Province of British Columbia who had planned for their birth to be at home with a regulated midwife in attendance to answer an open-ended question about positive and negative aspects of their birth. The qualitative method of interpretive description was used to understand what women believed to be the essence of their experience., Results: Women felt strongly positive about their trust in their midwife's skill and knowledge, a sense of emotional support and empowerment attained through their relationship with the midwife, perceptions of relaxation in their own home, being informed and included in the planning of their care, and the amount of time the midwife spent with their family. They believed that the confidence arising from their intense preparation and partnership with their midwives permitted them to choreograph their birth experience to a degree that would not be possible in a formal setting., Conclusions: Women who planned a home birth with a registered midwife in British Columbia were overwhelmingly positive about their experience. Our qualitative report underscores the value women place on having the choice to give birth at home.

Objective: South Asian women face multiple barriers to accessing information and support if they are experiencing spousal abuse. We conducted a study among South Asian women in Surrey, British Columbia, to define a role for obstetrical care providers in assisting women who experience family violence., Methods: South Asian women survivors of abuse participated with representatives of family and victim services agencies in a workshop to identify key opportunities for violence prevention and intervention by obstetrical care providers. Participants grouped issues affecting women's vulnerability to violence into four themes and identified strategies to address them., Results: Themes focused on cultural issues, services and supports, education and prevention, and policy and advocacy. Participants highlighted challenges posed by the patriarchal nature of their culture and, for many families, by recent immigration. They emphasized the importance of routine assessment for family violence by obstetrical care providers and stressed the need to treat the entire family, not just the identified victim. They focused on the role of the caregiver as a conduit of information about social services and other resources. Community-level interventions to address abuse were endorsed, including the use of lay media to deliver key messages about health and safety., Conclusion: Pregnancy offers caregivers an opportunity to be advocates and to provide information and referrals for women in the South Asian community who may be at risk of violence. Obstetrical caregivers may be an important influence in protecting women from lethal harm.

Background: Preference for formula versus breast feeding among women of Chinese descent remains a concern in North America. The goal of this study was to develop an intervention targeting Chinese immigrant mothers to increase their rates of exclusive breastfeeding., Methods: We convened a focus group of immigrant women of Chinese descent in Vancouver, British Columbia to explore preferences for method of infant feeding. We subsequently surveyed 250 women of Chinese descent to validate focus group findings. Using a participatory approach, our focus group participants reviewed survey findings and developed a priority list for attributes of a community-based intervention to support exclusive breastfeeding in the Chinese community. The authors and focus group participants worked as a team to plan, implement and evaluate a Chinese language newborn feeding information telephone service staffed by registered nurses fluent in Chinese languages., Results: Participants in the focus group reported a strong preference for formula feeding. Telephone survey results revealed that while pregnant Chinese women understood the benefits of breastfeeding, only 20.8% planned to breastfeed exclusively. Only 15.6% were breastfeeding exclusively at two months postpartum. After implementation of the feeding hotline, 20% of new Chinese mothers in Vancouver indicated that they had used the hotline. Among these women, the rate of exclusive breastfeeding was 44.1%; OR 3.02, (95% CI 1.78-5.09) compared to women in our survey., Conclusion: Initiation of a language-specific newborn feeding telephone hotline reached a previously underserved population and may have contributed to improved rates of exclusive breastfeeding.

Objectives: To determine whether older women with exudative age-related macular degeneration (AMD) are at greater risk of falls., Design: Cross-sectional study., Setting: A hospital-based ophthalmology clinic in Vancouver, Canada., Participants: One hundred fifteen older (aged > or = 70) community-dwelling women with exudative AMD (AMD cohort) and two control groups: 54 community-dwelling women without exudative AMD drawn from the same community (non-AMD cohort) and 341 community-dwelling Australian women (Australian normative cohort)., Measurements: Participants were assessed for falls risk using the short-form Physiological Profile Assessment (PPA), which provides a fall risk index score and subcomponent measures of vision, proprioception, strength, reaction time, and postural sway., Results: The mean fall risk index score in the AMD cohort (3.20) was significantly greater than that of the non-AMD cohort (1.21; P<.001), and fall risk scores increased with age to a greater extent in the AMD cohort. The higher fall risk scores in the AMD cohort resulted from significantly worse performance on each PPA test, not just the test of vision. The AMD cohort also performed worse than the Australian normative cohort in tests of vision, reaction time, and postural sway., Conclusion: Older women with AMD have impaired balance, slow visual reaction times, and poor vision, which in combination result in a significantly greater risk of falls than population norms. These deficits are clearly indicated in the physiological falls profile for the group. Strategies to enhance balance may be particularly beneficial to prevent falls in this group.

Objective: To evaluate the effect of rooming-in (rather than standard nursery care) on the incidence and severity of neonatal abstinence syndrome among opioid-exposed newborns and on the proportion of mothers who retain custody of their babies at hospital discharge., Design: Retrospective cohort study., Setting: Lower mainland in southwestern British Columbia., Participants: We selected 32 women in the city of Vancouver known to have used heroin or methadone during pregnancy between October 2001 and December 2002. Comparison groups were a historical cohort of 38 women in Vancouver and a concurrent cohort of 36 women cared for in a neighbouring community hospital., Main Outcome Measures: Need for treatment with morphine, number of days of treatment with morphine, and whether babies were discharged in the custody of their mothers., Results: Rooming-in was associated with a significant decrease in need for treatment of neonatal abstinence syndrome compared with the historical cohort (adjusted relative risk [RR] 0.40, 95% confidence interval [CI] 0.20 to 0.78) and the concurrent cohort (adjusted RR 0.39, 95% CI 0.20 to 0.75). Rooming-in was also associated with shorter newborn length of stay in hospital compared with both comparison groups. Newborns who roomed in at BC Women's Hospital were significantly more likely to be discharged in the custody of their mothers than babies in the historical cohort (RR 2.23, 95% CI 1.43 to 3.98) or the concurrent cohort (RR 1.52, 95% CI 1.15 to 2.53) were., Conclusion: Rooming-in might ease opioid-exposed newborns' transition to extrauterine life and promote more effective mothering.

Purpose: Because behavioral sleep problems affect a large proportion of infants and can result in health issues for children and their parents, the study evaluated the effects of a sleep intervention for infants from 6 to 12 months old., Method: For this quasi-experimental one group pre-test and post-test design, 39 eligible families were recruited through a newborn hotline. Seventy parents with healthy 6 to 12-month old infants completed the intervention. The intervention involved information about infant sleep and strategies for sleep problems in classes of up to 6 couples, chart completion, and bi-weekly telephone calls for 2 weeks. The primary outcome measures were parents' sleep quality, fatigue, cognitions about infant sleep, depression, marital harmony, and sleepiness., Findings: Following the intervention, there was a significant improvement in parents' sleep quality, cognitions about infant sleep, fatigue, and depressed mood., Conclusions: The study findings demonstrated that providing parents with information and support to assist with infant behavioral sleep problems can improve parental psychological well being.

The purpose of this study was to compare satisfaction with the birth experience among a population of women planning birth at home versus in hospital. In British Columbia, Canada, all midwives offer women meeting eligibility requirements for homebirth the choice to give birth in hospital or at home. Therefore, satisfaction can be attributed to planned place of birth, as the caregivers were the same in both settings. The mean overall score on the Labour Agentry Scale among women who had planned a homebirth (n = 550), 188.49 +/- 16.85, was significantly higher than those who planned birth in hospital (n = 108), 176.60 +/- 23.79; P < .001. Overall satisfaction with the birth experience was higher among women planning birth at home, 4.87 +/- 0.42 versus 4.80 +/- 0.49 on a scale of 1 to 5, although this difference was not statistically significant; P = .06. Among women whose actual place of birth was congruent with where they had planned, overall satisfaction was higher in the homebirth group, 4.95 +/- 0.20 versus 4.75 +/- 0.53; P < .001. Although satisfaction with the birth experience was high in both the home and hospital settings, women planning birth at home were somewhat more satisfied with their experience, particularly if they were able to complete the birth at home.

This paper describes the development and psychometric assessment of a scale to measure satisfaction with intrapartum and postpartum care in hospital: The Care in Obstetrics: A Measure For Testing Satisfaction (COMFORTS) scale. A sample of 415 participants completed the 40-item scale. Cronbach's alpha for the scale was .95. Evaluation of construct validity through principal components factor analysis with varimax rotation yielded six subscales: confidence in newborn care, postpartum nursing care, provision of choice, the physical environment, respect for privacy, and labor/delivery nursing care. The COMFORTS scale was able to discriminate between multiparous versus primiparous women, and between women cared for in single room maternity care versus in separate labor/delivery and postpartum rooms. Pending further validation, the COMFORTS scale has potential to measure women's satisfaction with childbirth care and contribute to an assessment of the quality of care provided., (Copyright 2006 Wiley Periodicals, Inc.)

Aims and Objectives: To evaluate the success of a competency-based nursing orientation programme for a single-room maternity care unit by measuring improvement in self-reported competency after six months., Background: Single-room maternity care has challenged obstetrical nurses to provide comprehensive nursing care during all phases of the in-hospital birth experience. In this model, nurses provide intrapartum, postpartum and newborn care in one room. To date, an evaluation of nursing education for single-room maternity care has not been published., Design: A prospective cohort design comparing self-reported competencies prior to starting work in the single-room maternity care and six months after., Methods: Nurses completed a competency-based education programme in which they could select from a menu of learning methods and content areas according to their individual needs. Learning methods included classroom lectures, self-paced learning packages, and preceptorships in the clinical area. Competencies were measured by a standardized perinatal self-efficacy tool and a tool developed by the authors for this study, the Single-Room Maternity Care Competency Tool. A paired analysis was undertaken to take into account the paired (before and after) nature of the design., Results: Scores on the perinatal self-efficacy scale and the single-room maternity care competency tool were improved. These differences were statistically significant., Conclusions: Improvements in perinatal and single-room maternity care-specific competencies suggest that our education programme was successful in preparing nurses for their new role in the single-room maternity care setting. This conclusion is supported by reported increases in nursing and patient satisfaction in the single-room maternity care compared with the traditional labour/delivery and postpartum settings., Relevance to Clinical Practice: An education programme tailored to the learning needs of experienced clinical nurses contributes to improvements in nursing competencies and patient care.

Objectives: (1) To compare perinatal outcomes and costs of care among women giving birth in a single room maternity care (SRMC) setting versus a traditional delivery suite or postpartum setting; and (2) to report on physicians' responses to the SRMC environment., Methods: Among women who were determined to be at "low risk" for intrapartum complications through the use of a triage tool, the outcomes of those receiving care in the new SRMC unit were compared to the outcomes of those cared for in the traditional delivery suite and postpartum modules. Total costs of the entire maternity service before and after implementation of SRMC were also compared. Physicians were surveyed about the adequacy of the physical environment., Results: Rates of intrapartum interventions and adverse outcomes were similar in both groups, with the exception of less frequent electronic fetal monitoring in the SRMC setting. Caesarean section rates were lower than expected in both groups. Length of stay was significantly shorter in the SRMC group (55.1 +/- 26.5 days vs. 61.0 +/- 24.3 days; <.001). Staff positions in the hospital were reduced from 206 to 193.7. Direct costs for women of similar acuity (resource intensity weightings) were reduced by 24% (1809 dollars vs. 2377 dollars). The proportion of physicians preferring SRMC to the traditional setting increased from 45.8% at 6 months to 78.7% at 12 months after implementation of the SRMC model (P =.003)., Conclusion: SRMC is a model of obstetric care for women at low risk for intrapartum complications, offering cost savings without affecting perinatal outcomes, and is well accepted by physicians.

Objective: To gain a better understanding of ethnic Chinese women's perceptions and experiences of using barrier and rhythm methods of contraception in order to improve contraceptive counseling at abortion clinics., Design: Qualitative descriptive study., Setting: Urban abortion clinic., Participants: Forty ethnic Chinese women presenting for abortion., Method: Data were collected in semi-structured interviews by one interviewer who is fluent in English, Mandarin and Cantonese. Transcribed interviews were systematically analyzed to identify salient themes., Main Findings: All of the women interviewed had used condoms (none with spermicide), 20 had used rhythm and 17 withdrawal, usually a combination of two or three of these methods. Many women noted that these methods are under male control and talked about the difficulty negotiating their use with partners. The majority of women using rhythm were unable to correctly identify "safe periods.", (Copyright 2004 Elsevier Inc.)

Objective: To compare childbirth outcomes of women prospectively randomized to receive early labour assessment and support either through a home visit or by telephone triage., Methods: Women in early labour, upon seeking prior telephone advice on whether or not they were ready to be admitted to BC Women's Hospital (as was standard hospital practice), were voluntarily randomized to receive either a home visit by an obstetrical nurse or telephone triage., Results: One hundred seventeen women were randomized to receive home care and 120 to receive telephone triage. Significantly fewer women in the home care group arrived at hospital in the latent stage of labour, compared to women in the telephone triage group (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.19-0.72). Significantly fewer women in the home care group received narcotics (OR, 0.55; 95% CI, 0.32-0.96). Differences observed in use of epidural analgesia (OR, 0.64; 95% CI, 0.36-1.16) were not statistically significant. Newborns in the home care group were significantly less likely to be admitted to a level II observation nursery (OR, 0.13; 95% CI, 0.03-0.60). More women in the home care group would recommend this type of care to a friend (P = 0.001)., Conclusion: Our findings suggest an association of early labour assessment at home with both admission to hospital in the active phase of labour and reduction in use of analgesia during labour. Early labour support at home was associated with reduced rates of admission of neonates to a level II observation nursery, possibly secondary to reduced exposure to analgesics. Early labour care at home by hospital-based obstetrical nurses is safe and acceptable to women, and may offer advantages in terms of reduced interventions and more vigorous neonates.

Midwifery emerged as a self-regulated profession in British Columbia in the context of a 2-year demonstration project beginning in 1998. The project evaluated accountability among midwives, defined as the provision of safe and appropriate care and maintenance of standards of communication set by the College of Midwives of British Columbia. Adherence to protocols was measured by using documentation designed specifically for the Home Birth Demonstration Project. Hospital and transport records for selected clients were reviewed by an expert committee. Outcomes among Home Birth Demonstration Project clients were compared with outcomes among women eligible for home birth but planning to deliver in hospital. Adherence to clinical and communication protocols was 96% or higher. Planned home birth was not associated with an increase in risk but prevalence of adverse outcomes was too low to be studied with precision. Recommendations of an expert review committee have been implemented or are under review. Midwives have demonstrated a high degree of compliance with reporting requirements and protocols. Comparisons of birth outcomes of planned home versus hospital births, while supporting home birth as a choice for women, were limited in scope and require ongoing study. Integration of home birth has been a dynamic process with guidelines and policy continuing to evolve.

Background: The choice to give birth at home with a regulated midwife in attendance became available to expectant women in British Columbia in 1998. The purpose of this study was to evaluate the safety of home birth by comparing perinatal outcomes for planned home births attended by regulated midwives with those for planned hospital births., Methods: We compared the outcomes of 862 planned home births attended by midwives with those of planned hospital births attended by either midwives (n = 571) or physicians (n = 743). Comparison subjects who were similar in their obstetric risk status were selected from hospitals in which the midwives who were conducting the home births had hospital privileges. Our study population included all home births that occurred between Jan. 1, 1998, and Dec. 31, 1999., Results: Women who gave birth at home attended by a midwife had fewer procedures during labour compared with women who gave birth in hospital attended by a physician. After adjustment for maternal age, lone parent status, income quintile, use of any versus no substances and parity, women in the home birth group were less likely to have epidural analgesia (odds ratio 0.20, 95% confidence interval [CI] 0.14-0.27), be induced, have their labours augmented with oxytocin or prostaglandins, or have an episiotomy. Comparison of home births with hospital births attended by a midwife showed very similar and equally significant differences. The adjusted odds ratio for cesarean section in the home birth group compared with physician-attended hospital births was 0.3 (95% CI 0.22-0.43). Rates of perinatal mortality, 5-minute Apgar scores, meconium aspiration syndrome or need for transfer to a different hospital for specialized newborn care were very similar for the home birth group and for births in hospital attended by a physician. The adjusted odds ratio for Apgar scores lower than 7 at 5 minutes in the home birth group compared with physician-attended hospital births was 0.84 (95% CI 0.32-2.19)., Interpretation: There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife. The rates of some adverse outcomes were too low for us to draw statistical comparisons, and ongoing evaluation of home birth is warranted.