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Purpose: To develop and psychometrically test a comprehensive measure of preconception health knowledge., Design: Cross-sectional survey, in May and June, 2019., Setting: Alberta, Ontario, and Québec, Canada., Sample: One thousand seven hundred seventy-seven women and men with ≥1 children born in the last 5 years or planning a pregnancy in the next 5 years., Measures: Using prior literature and input from public health nurses and physicians, the Preconception Health Knowledge Questionnaire (PHKQ) was developed and comprised 25 multiple choice questions on reproductive history, sexual health, infectious diseases, chronic medical conditions, mental health, medications, immunizations, lifestyle behaviors, psychosocial stressors, and environmental exposures., Analysis: Psychometric testing was undertaken to evaluate item difficulty, discrimination, quality of response alternatives, internal consistency, and construct validity., Results: Participants had a mean total score of 15.8/25 (SD = 3.9); women and men had mean total scores of 16.2 (SD = 3.6) and 13.8 (SD = 4.7), respectively. Most items were neither too difficult nor too easy, discriminated well between participants with high and low knowledge, and had appropriate response alternatives. High internal consistency (KR-20 = 0.87) and construct validity, shown via significant correlations with education level and previous preconception care receipt, were demonstrated., Conclusion: The PHKQ is a reliable and valid tool for measuring preconception health knowledge and may be useful in identification of high-risk groups in need of preconception health education and evaluation of preconception health interventions.

Background: As cannabis consumption is increasing globally, including among pregnant women, there is a critical need to understand the effects of cannabis on fetal development and birth outcomes. We had two objectives: to determine 1) the factors associated with self-reported cannabis use in the pre/early-pregnancy period, and 2) whether cannabis use is associated with low birth weight, preterm birth, or small size for gestational age (GA) infants., Methods: Maternal questionnaire and birth outcome data was gathered from 2229 women and 1778 singleton infants in the Ontario Birth Study, a hospital-based prospective cohort study (2013-2019). Women self-reported cannabis use within 3 months of learning their pregnancy status. Multivariable linear and logistic regression was conducted to 1) identify factors associated with cannabis use, and 2) determine the associations between cannabis use with the selected birth outcomes., Results: Cannabis use increased in the cohort over time. Women who reported cannabis use (N = 216) were more likely to be younger and more likely to use alcohol, tobacco, and prescription pain medication, although most did not. These women had infants born at lower average birth weights and had 2.0 times the odds of being small for GA (95% confidence interval: 1.3, 3.3) after multivariable adjustment for socioeconomic factors and other substance use., Conclusion: Our results suggest that women who use cannabis around the time of conception have higher odds of having infants that are small for gestational age. Targeted clinical messaging may be most applicable to women actively trying to conceive.

Purpose: COVID-19 (Coronavirus Disease 2019) was first reported in December 2019 and quickly swept across China and around the world. Levels of anxiety and depression were increased among pregnant women during this infectious pandemic. Thyroid function is altered during stressful experiences, and any abnormality during early pregnancy may significantly affect fetal development and pregnancy outcomes. This study aimed to determine whether the COVID-19 pandemic induces thyroid hormone changes in early pregnant women., Methods: This study comprised two groups of pregnant women in Shanghai in their first trimester - those pregnant women before the COVID-19 outbreak from January 20, 2019, to March 31, 2019 (Group 1) and those pregnant during the COVID-19 outbreak from January 20, 2020, to March 31, 2020 (Group 2). All women were included if they had early pregnancy thyrotropin (TSH), free triiodothyronine (FT3), free thyroxine (FT4), total triiodothyronine (TT3), and total thyroxine (TT4) concentrations, thyroid peroxidase (TPO) antibody or thyroglobulin antibody (TgAb) available and did not have a history of thyroid diseases or received thyroid treatment before or during pregnancy. We used propensity score matching to form a cohort in which patients had similar baseline characteristics., Results: Among 3338 eligible pregnant women, 727 women in Group 1 and 727 in Group 2 had similar propensity scores and were included in the analyses. Pregnant women in Group 2 had significantly higher FT3 (5.7 vs. 5.2 pmol/L, P<0.001) and lower FT4 (12.8 vs. 13.2 pmol/L, P<0.001) concentrations compared with those in Group 1. Pregnant women in Group 2 were more likely to develop isolated hypothyroxinemia (11.6% vs. 6.9%, OR, 1.75 [95% CI, 1.20-2.53], P =0.003) than those in Group 1 but had a significantly lower risk of TgAb positivity (12.0% vs. 19.0%, OR, 0.58 [95% CI, 0.43-0.78], P <0.001)., Conclusion: Pregnant women in their first trimester in Shanghai during the COVID-19 outbreak were at an increased risk of having higher FT3 concentrations, lower FT4 concentrations, and isolated hypothyroxinemia. The association between thyroid hormones, pregnancy outcomes, and the COVID-19 outbreak should be explored further., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2020 Lin, Zhang, Zhang, Wang, Chen, Dennis, Huang and Wu.)

Objectives: To examine the relationship between prepregnancy chronic medical conditions (CMCs) and the risk of acute perinatal psychiatric health-care encounters (i.e., psychiatric emergency department visits, hospitalizations) among refugees, nonrefugee immigrants, and long-term residents in Ontario., Methods: We conducted a population-based study of 15- to 49-year-old refugees ( N = 29,189), nonrefugee immigrants ( N = 187,430), and long-term residents ( N = 641,385) with and without CMC in Ontario, Canada, with a singleton live birth in 2005 to 2015 and no treatment for mental illness in the 2 years before pregnancy. Modified Poisson regression was used to estimate the relative risk of a psychiatric emergency department visit or hospitalization from conception until 1 year postpartum among women with versus without CMC, stratified by migrant status. An unstratified model with an interaction term between CMC and migrant status was used to test for multiplicativity of effects., Results: The association between CMC and risk of a psychiatric emergency department visit or hospitalization was stronger among refugees (adjusted relative risk [aRR] = 1.87; 95% confidence interval [CI], 1.36 to 2.58) compared to long-term residents (aRR = 1.39; 95% CI, 1.30 to 1.48; interaction P = 0.047). The strength of the association was no different in nonrefugee immigrants (aRR = 1.26; 95% CI, 1.05 to 1.51) compared to long-term residents (interaction P = 0.45)., Conclusion: Our study identifies refugee women with CMC as a high-risk group for acute psychiatric health care in the perinatal period. Preventive psychosocial interventions may be warranted to enhance supportive resources for all women with CMC and, in particular refugee women, to reduce the risk of acute psychiatric health care in the perinatal period.

Objective: Understanding the effects of benzodiazepines (BZDs) on maternal/fetal health remains incomplete despite their frequent use. This article quantifies the effects of antenatal BZD exposure on delivery outcomes., Data Sources: Medline, PsycINFO, CINAHL, Embase, and the Cochrane Library were searched till June 30, 2018., Study Selection: English-language cohort studies comparing antenatal BZD exposure to an unexposed group on any delivery outcome were eligible. In all, 23,909 records were screened, 56 studies were assessed, and 14 studies were included., Data Extraction: Two reviewers independently assessed quality and extracted data. Estimates were pooled using random effects meta-analysis. Sub-analyses examined several potential moderators including timing of exposure., Results: There were 9 outcomes with sufficient data for meta-analysis. Antenatal BZD exposure was significantly associated with increased risk of 6 outcomes initially: spontaneous abortion (pooled odds ratio = 1.86; 95% confidence interval [CI], 1.43 to 2.42), preterm birth (1.96; 95% CI, 1.25 to 3.08), low birth weight (2.24; 95% CI, 1.41 to 3.88), low Apgar score (2.19; 95% CI, 1.94 to 2.47), Neonatal Intensive Care Unit (NICU) admission (2.61; 95% CI, 1.64 to 4.14), and induced abortion (2.04; 95% CI, 1.23 to 3.40). There was significant heterogeneity between studies for most outcomes without consistent moderators. Birth weight (mean difference [MD]: -151.35 g; 95% CI, -329.73 to 27.03), gestational age (-0.49 weeks; 95% CI, -1.18 to 0.19), and small for gestational age (SGA; 1.42; 95% CI, 1.00 to 2.01) did not show significant associations although after adjusting for publication bias, gestational age, and SGA became significant, totaling 8 significant outcomes., Conclusions: Antenatal BZD exposure appears to be statistically associated with increased risk of several adverse perinatal outcomes. Although confounds cannot be ruled out, NICU admission does appear clinically relevant and consistent with the antidepressant literature.

Introduction: In the United Arab Emirates, an alarming rate of 19% obesity among adolescents, associated with poor lifestyle, is apparent. Diet and exercise self-efficacy could influence adolescents' engagement in healthy behaviors. This study evaluates adolescents' perceptions of diet and exercise self-efficacy and explores the impact of parents and schools on self-efficacy. Method : A cluster sampling approach in cross-sectional design was used to recruit 610 school adolescents (Grades 7-12) over a 6-month period. Information on sociodemographics, lifestyle, parents, and schools was explored. Self-efficacy was assessed using The Eating Habits and Exercise Confidence Survey. Results: Participants reported moderate diet and exercise self-efficacy. Diet self-efficacy was predicted by parental support, eating breakfast and meals regularly at home, and prohibiting soft drinks. School support and frequency of weekly exercise classes predicted exercise self-efficacy; p values ≤.05. Discussion: Cultural knowledge and collaboration are essential to promote self-efficacy in multiethnic adolescents in the United Arab Emirates.

Objectives: Preconception health impacts perinatal outcomes, but the difficulty in engaging reproductive-aged individuals in health promotion activities is a barrier to effective implementation of preconception interventions. Since most women have more than one pregnancy and many risk factors repeat across pregnancies, the time between pregnancies-the interconception period-may be an opportune time to improve health. Our objective was to examine the feasibility and acceptability of an interconception intervention delivered by public health nurses., Methods: We conducted a pilot randomized controlled trial in three small urban and rural public health units in Ontario, Canada, in 2017-2018 among women who were ≥ 18 years of age and between 2 and 12 months postpartum after a first birth. Women randomly allocated to the intervention group received a preconception risk assessment, tailored health education, and referral for clinical follow-up as needed, while those in the control group received standard care. Primary outcomes were intervention feasibility, adherence, and acceptability., Results: Of 66 eligible women, 61% agreed to participate and were randomized to the intervention (n = 16) or control (n = 24) groups. The follow-up rate was 78% at 1 month and 71% at 3 months. Most women (83%) were satisfied with the intervention, including the number and length of sessions and content of recommendations., Conclusions for Practice: Results demonstrate the potential feasibility and acceptability of an interconception intervention delivered in a public health setting. The short- and long-term impacts of the intervention on knowledge, behavior, and health should be tested in a larger sample.

Background: Task sharing has been used worldwide to improve access to mental health care, where nonspecialist providers-individuals with no formal training in mental health-have been trained to effectively treat perinatal depressive and anxiety symptoms. Little formative research has been conducted to examine relevant barriers and facilitators of nonspecialist providers and the use of telemedicine in treatment service delivery., Objective: The primary objective of this study was to examine the main barriers and facilitators of nonspecialist provider-delivered psychological treatments for perinatal populations with common mental health disorders, such as depression and anxiety, from a multistakeholder perspective., Methods: This study took place in Toronto, Canada. In total, 33 in-depth interviews were conducted with multiple stakeholder groups (women with lived experience and their significant others, as well as health and mental health professionals). Qualitative data were quantified to estimate commonly endorsed themes within and across stakeholder groups., Results: Psychological treatments delivered by nonspecialist providers were considered acceptable by the vast majority of participants (30/33, 90%). Across all stakeholder groups, nurses (20/33, 61%) and midwives (14/33, 42%) were the most commonly endorsed cadre of nonspecialist providers. The majority of stakeholders (32/33, 97%) were amenable to nonspecialist providers delivering psychological treatment via telemedicine (27/33, 82%), although concerns were raised about the ability to establish a therapeutic alliance via telemedicine (16/33, 48%). Empathy was the most desired characteristic of a nonspecialist provider (61%). Patient and patient advocate stakeholders were more likely to emphasize stigma as an important barrier to accessing psychological treatments (7/12, 58%), compared to clinicians (2/9, 22%) and spouses (1/5, 20%). Clinician stakeholders were more likely to emphasize the importance of ensuring nonspecialist providers were trained to deliver psychological treatments (3/9, 33%), compared to other stakeholder groups., Conclusions: These results can inform the design, implementation, and integration of nonspecialist-delivered interventions via telemedicine for women with perinatal depressive and anxiety symptoms in high-income country contexts., (©Daisy Radha Singla, Sasha Lemberg-Pelly, Andrea Lawson, Nika Zahedi, Tyla Thomas-Jacques, Cindy-Lee Dennis. Originally published in JMIR Mental Health (http://mental.jmir.org), 27.08.2020.)

Objective: To assess whether vaginal secretions and breast milk of women with coronavirus disease 2019 (COVID-19) contain severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)., Design: Single centre cohort study., Setting: Renmin Hospital of Wuhan University, Wuhan, Hubei province, China., Population: We studied 13 SARS-CoV-2-infected pregnant women diagnosed between 31 January and 9 March 2020., Methods: We collected clinical data, vaginal secretions, stool specimens and breast milk from SARS-CoV-2-infected women during different stages of pregnancy and collected neonatal throat and anal swabs., Main Outcomes and Measures: We assessed viral presence in different biosamples., Results: Of the 13 women with COVID-19, five were in their first trimester, three in their second trimester and five in their third trimester. Of the five women in their third trimester who gave birth, all delivered live newborns. Among these five deliveries, the primary adverse perinatal outcomes included premature delivery (n = 2) and neonatal pneumonia (n = 2). One of nine stool samples was positive; all 13 vaginal secretion samples, and five throat swabs and four anal swabs collected from neonates, were negative for the novel coronavirus. However, one of three samples of breast milk was positive by viral nucleic acid testing., Conclusions: In this case series of 13 pregnant women with COVID-19, we observed negative viral test results in vaginal secretion specimens, suggesting that a vaginal delivery may be a safe delivery option. However, additional research is urgently needed to examine breast milk and the potential risk for viral contamination., Tweetable Abstract: New evidence for the safety of vaginal delivery and breastfeeding in pregnant women infected with SARS-CoV-2, positive viral result in a breast-milk sample., (© 2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

Background: On January 20, 2020, a new coronavirus epidemic with human-to-human transmission was officially declared by the Chinese government, which caused significant public panic in China. In light of the coronavirus disease 2019 outbreak, pregnant women may be particularly vulnerable and in special need for preventive mental health strategies. Thus far, no reports exist to investigate the mental health response of pregnant women to the coronavirus disease 2019 outbreak., Objective: This study aimed to examine the impact of coronavirus disease 2019 outbreak on the prevalence of depressive and anxiety symptoms and the corresponding risk factors among pregnant women across China., Study Design: A multicenter, cross-sectional study was initiated in early December 2019 to identify mental health concerns in pregnancy using the Edinburgh Postnatal Depression Scale. This study provided a unique opportunity to compare the mental status of pregnant women before and after the declaration of the coronavirus disease 2019 epidemic. A total of 4124 pregnant women during their third trimester from 25 hospitals in 10 provinces across China were examined in this cross-sectional study from January 1, 2020, to February 9, 2020. Of these women, 1285 were assessed after January 20, 2020, when the coronavirus epidemic was publicly declared and 2839 were assessed before this pivotal time point. The internationally recommended Edinburgh Postnatal Depression Scale was used to assess maternal depression and anxiety symptoms. Prevalence rates and risk factors were compared between the pre- and poststudy groups., Results: Pregnant women assessed after the declaration of coronavirus disease 2019 epidemic had significantly higher rates of depressive symptoms (26.0% vs 29.6%, P=.02) than women assessed before the epidemic declaration. These women were also more likely to have thoughts of self-harm (P=.005). The depressive rates were positively associated with the number of newly confirmed cases of coronavirus disease 2019 (P=.003), suspected infections (P=.004), and deaths per day (P=.001). Pregnant women who were underweight before pregnancy, primiparous, younger than 35 years, employed full time, in middle income category, and had appropriate living space were at increased risk for developing depressive and anxiety symptoms during the outbreak., Conclusion: Major life-threatening public health events such as the coronavirus disease 2019 outbreak may increase the risk for mental illness among pregnant women, including thoughts of self-harm. Strategies targeting maternal stress and isolation such as effective risk communication and the provision of psychological first aid may be particularly useful to prevent negative outcomes for women and their fetuses., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: As of June 1, 2020, coronavirus disease 2019 (COVID-19) has caused more than 6,000,000 infected persons and 360,000 deaths globally. Previous studies revealed pregnant women with COVID-19 had similar clinical manifestations to nonpregnant women. However, little is known about the outcome of neonates born to infected women., Methods and Findings: In this retrospective study, we studied 29 pregnant women with COVID-19 infection delivered in 2 designated general hospitals in Wuhan, China between January 30 and March 10, 2020, and 30 neonates (1 set of twins). Maternal demographic characteristics, delivery course, symptoms, and laboratory tests from hospital records were extracted. Neonates were hospitalized if they had symptoms (5 cases) or their guardians agreed to a hospitalized quarantine (13 cases), whereas symptom-free neonates also could be discharged after birth and followed up through telephone (12 cases). For hospitalized neonates, laboratory test results and chest X-ray or computed tomography (CT) were extracted from hospital records. The presence of antibody of SARS-CoV-2 was assessed in the serum of 4 neonates. Among 29 pregnant COVID-19-infected women (13 confirmed and 16 clinical diagnosed), the majority had higher education (56.6%), half were employed (51.7%), and their mean age was 29 years. Fourteen women experienced mild symptoms including fever (8), cough (9), shortness of breath (3), diarrhea (2), vomiting (1), and 15 were symptom-free. Eleven of 29 women had pregnancy complications, and 27 elected to have a cesarean section delivery. Of 30 neonates, 18 were admitted to Wuhan Children's Hospital for quarantine and care, whereas the other 12 neonates discharged after birth without any symptoms and had normal follow-up. Five hospitalized neonates were diagnosed as COVID-19 infection (2 confirmed and 3 suspected). In addition, 12 of 13 other hospitalized neonates presented with radiological features for pneumonia through X-ray or CT screening, 1 with occasional cough and the others without associated symptoms. SARS-CoV-2 specific serum immunoglobulin M (IgM) and immunoglobulin G (IgG) were measured in 4 neonates and 2 were positive. The limited sample size limited statistical comparison between groups., Conclusions: In this study, we observed COVID-19 or radiological features of pneumonia in some, but not all, neonates born to women with COVID-19 infection. These findings suggest that intrauterine or intrapartum transmission is possible and warrants clinical caution and further investigation., Trial Registration: Chinese Clinical Trial Registry, ChiCTR2000031954 (Maternal and Perinatal Outcomes of Women with coronavirus disease 2019 (COVID-19): a multicenter retrospective cohort study)., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: BWM is supported by a NHMRC Investigator grant (GNT1176437). BWM reports consultancy for ObsEva, Merck KGaA, iGenomix and Guerbet. These consultancies are not related to the current work. All other authors report no potential competing interests.

Recent discoveries from large-scale genome-wide association studies (GWASs) explain a larger proportion of the genetic variability to BMI and obesity. The genetic risk associated with BMI and obesity can be assessed by an obesity-specific genetic risk score (GRS) constructed from genome-wide significant genetic variants. The aim of our study is to examine whether the duration and exclusivity of breastfeeding can attenuate BMI increase during childhood and adolescence due to genetic risks. A total sample of 5,266 children (2,690 boys and 2,576 girls) from the Avon Longitudinal Study of Parents and Children (ALSPAC) was used for the analysis. We evaluated the role of breastfeeding (exclusivity and duration) in modulating BMI increase attributed to the GRS from birth to 18 years of age. The GRS was composed of 69 variants associated with adult BMI and 25 non-overlapping SNPs associated with pediatric BMI. In the high genetic susceptible group (upper GRS quartile), exclusive breastfeeding (EBF) to 5 months reduces BMI by 1.14 kg/m2 (95% CI, 0.37 to 1.91, p = 0.0037) in 18-year-old boys, which compensates a 3.9-decile GRS increase. In 18-year-old girls, EBF to 5 months decreases BMI by 1.53 kg/m2 (95% CI, 0.76 to 2.29, p<0.0001), which compensates a 7.0-decile GRS increase. EBF acts early in life by delaying the age at adiposity peak and at adiposity rebound. EBF to 3 months or non-exclusive breastfeeding was associated with a significantly diminished impact on reducing BMI growth during childhood. EBF influences early life growth and development and thus may play a critical role in preventing overweight and obesity among children at high-risk due to genetic factors., Competing Interests: The authors have declared that no competing interests exist.

We examined the risk of any perinatal mental illness associated with prepregnancy diabetes and identified how diabetes duration, complexity, and intensity of care affect this risk. We performed a population-based study of women aged 15-49 years with (n = 14,186) and without (n = 843,818) prepregnancy diabetes who had a singleton livebirth (Ontario, Canada, 2005-2015) and no recent mental illness. Modified Poisson regression estimated perinatal mental illness risk between conception and 1 year postpartum in women with versus without diabetes and in diabetes groups, defined by a latent class analysis of diabetes duration, complexity, and intensity-of-care variables, versus women without diabetes. Women with diabetes were more likely than those without to develop perinatal mental illness (18.1% vs. 16.0%; adjusted relative risk = 1.11, 95% confidence interval: 1.07, 1.15). Latent classes of women with diabetes were: uncomplicated and not receiving regular care (59.7%); complicated, with longstanding diabetes, and receiving regular care (16.4%); and recently diagnosed, with comorbidities, and receiving regular care (23.9%). Perinatal mental illness risk was elevated in all classes versus women without diabetes (adjusted relative risks: 1.09-1.12), but results for class 2 were nonsignificant after adjustment. Women with diabetes could benefit from preconception and perinatal strategies to reduce their mental illness risk., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Postpartum depression (PPD) is prevalent among adolescent mothers and is associated with negative maternal and infant outcomes. Peer support can improve health outcomes among adult and adolescent populations and involves the provision of informational, emotional, and appraisal support delivered by a peer., Purpose: To describe adolescent mothers' perceptions of a mobile phone-based peer support (MPPS) intervention designed to prevent PPD., Methods: This analysis draws on data from the MPPS intervention group of a pilot randomized controlled trial of pregnant adolescents 17 to 24 years old ( n  = 16). Maternal perceptions of the intervention were measured using the validated Peer Support Evaluation Inventory at 12 weeks postpartum., Results: Participants acknowledged receiving supportive actions including emotional (91%), informational (66%), and appraisal (64%) support. Participants perceived positive relationship qualities with their peer mentor such as trustworthiness (94%), acceptance (75%), empathy (81%), and commitment (81%) and felt their peer mentor possessed social competence (91%) and social skills (91%). Overall, 100% of participants were satisfied with their peer support experience and would recommend this type of support to a friend., Conclusion: Participants perceived their experience with the MPPS intervention positively, which lends support to MPPS as an acceptable way to provide support to adolescent mothers.

Objective: To outline the development and evaluation of an online infertility peer supporter training program., Methods: Men and women with diverse infertility backgrounds were recruited and trained to provide online peer support to people undergoing fertility treatment. Training required volunteers to (1) read a peer support training manual, (2) watch a webinar, and (3) complete practice questions, each of which was evidence-based and reviewed by key stakeholders., Results: Seventeen women and one man were trained and provided online peer support. Program satisfaction was high and training materials were rated as helpful. Peer supporters felt comfortable providing support and having their discussions monitored. They liked helping others and the convenience of a mobile application., Conclusion: Online recruitment and training of infertility peer supporters is feasible. The current program was acceptable and offers steps for improving future online peer support interventions., Practice Implications: Current evidence supports the acceptability and feasibility of this training and supervision program, and provides service providers with information guiding its development and implementation., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: This proposed study aims to translate the Dietary Approach to Stop Hypertension with Sodium (Na) Reduction for Chinese Canadians (DASHNa-CC), a classroom-based, antihypertensive, dietary educational intervention, to an innovative smartphone app (mDASHNa-CC). This study will enable Chinese Canadian seniors to access antihypertensive dietary interventions anytime, regardless of where they are. It is hypothesized that senior Chinese Canadians will be satisfied with their experiences using the mDASHNa-CC app and that the use of this app could lead to a decrease in their blood pressure and improvement in their health-related quality of life., Objective: The goal of this study is to design and test the usability and feasibility of a smartphone-based dietary educational app to support a healthy diet and hypertension control for Chinese Canadian seniors., Methods: A mixed-method two-phase design will be used. The study will be conducted in a Chinese immigrant community in Toronto, Ontario, Canada. Chinese Canadian seniors, who are at least 65 years old, self-identified as Chinese, living in Canada, and with elevated blood pressure, will be recruited. In Phase I, we will design and test the usability of the app using a user-centered approach. In Phase II, we will test the feasibility of the app, including implementation (primary outcomes of accrual and attrition rates, technical issues, acceptability of the app, and adherence to the intervention) and preliminary effectiveness (secondary outcomes of systolic and diastolic blood pressure, weight, waist circumference, health-related quality of life, and health service utilization), using a pilot, two-group, randomized controlled trial with a sample size of 60 participants in a Chinese Canadian community., Results: The study is supported by the Startup Research Grant from Nipissing University, Canada. The research ethics application is under review by a university research ethics review board., Conclusions: The study results will make several contributions to the existing literature, including illustrating the rigorous design and testing of smartphone app technology for hypertension self-management in the community, exploring an approach to incorporating traditional medicine into chronic illness management in minority communities and promoting equal access to current technology among minority immigrant senior groups., Trial Registration: Clinicaltrials.gov NCT03988894; https://clinicaltrials.gov/ct2/show/NCT03988894., International Registered Report Identifier (irrid): PRR1-10.2196/15545., (©Ping Zou, Jennifer Stinson, Monica Parry, Cindy-Lee Dennis, Yeqin Yang, Zhongqiu Lu. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 02.04.2020.)

Aim: To develop a breastfeeding knowledge scale that aligns with the Baby Friendly Hospital Initiative and psychometrically test it among expectant parents., Background: Although breastfeeding is recommended by all leading health authorities, rates remain suboptimal with women often not achieving their breastfeeding goals. One factor found to positively influence infant feeding behaviours is increased maternal breastfeeding knowledge. However, little research has been conducted validating the dimensions of breastfeeding knowledge to guide interventions to promote positive breastfeeding outcomes., Design: Following an extensive literature review, the 28-item Comprehensive Breastfeeding Knowledge Scale (CBKS) was developed and psychometrically tested., Method: A sample of 217 Canadian expectant parents (113 women and 104 coparents) was recruited and administered the CBKS with follow-up questionnaires at 4 and 12 weeks postpartum. Psychometric analyses included exploratory factor analysis, internal consistency, concurrent validity, and predictive validity., Results: Exploratory factor analysis resulted in three dimensions: (1) managing milk supply; (2) persisting through challenges; and (3) correcting misconceptions. Coefficient alpha for the total scale was 0.83 and support for concurrent validity was demonstrated through significant positive correlations with the Iowa Infant Feeding Attitude scale. Further, higher total and subscale scores in pregnancy were associated with exclusive breastfeeding at 4 and 12 weeks postpartum, providing good evidence for predictive validity., Conclusion: Preliminary data suggest the CBKS is a valid and reliable measure of breastfeeding knowledge. Upon further testing, this self-report measure may be used to (1) identify women with low breastfeeding knowledge requiring targeted support, (2) individualize health professional care with breastfeeding women, and (3) evaluate the effectiveness of breastfeeding interventions and programs., Competing Interests: Declaration of Competing Interest None to declare., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Postpartum depression and anxiety are under-addressed public health problems with numerous treatment access barriers, including insufficiently available mental health specialist providers., Aims: To examine the effectiveness of nurse-delivered telephone interpersonal psychotherapy (IPT) for postpartum depression. Trial registration ISRCTN88987377., Method: Postpartum women (n = 241) with major depression (on the Structured Clinical Interview for DSM-IV (SCID-I)) from 36 Canadian public health regions in rural and urban settings were randomly assigned to 12 weekly 60 min nurse-delivered telephone-IPT sessions or standard locally available care. The primary outcome was the proportion of women clinically depressed at 12 weeks post-randomisation, with masked intention-to-treat analysis. Secondary outcomes examined included comorbid anxiety, self-reported attachment and partner relationship quality., Results: At 12 weeks, 10.6% of women in the IPT group (11/104) and 35% in the control group (35/100) remained depressed (OR = 0.22, 95% CI 0.10-0.46), with the IPT group 4.5 times less likely to be clinically depressed (SCID); 21.2% in the IPT group and 51% in the control group had an Edinburgh Postnatal Depression Scale (EPDS) score >12 (OR = 0.26, 95% CI 0.14-0.48), and attachment avoidance decreased more in the IPT group than in the control group (P = 0.02). Significant differences favoured the IPT group for comorbid anxiety and partner relationship quality at all time points, with no differences in health service or antidepressant use. None of the IPT responders relapsed by 36 weeks. Between-group SCID differences were sustained at 24 weeks, but not at 36 weeks., Conclusions: Nurse-delivered telephone IPT is an effective treatment for diverse urban and rural women with postpartum depression and anxiety that can improve treatment access disparities.

Objective: To describe the proportion of women with improving or worsening symptoms of fatigue at 1, 3, 6, and 12 months after birth; to model the trajectory of fatigue across the first year after birth and identify baseline predictors (e.g., immigrant status) and time-varying predictors; and to describe the degree to which fatigue interferes with activities of daily living across the first year after birth among a cohort of Chinese immigrant and Chinese Canadian-born women., Design: Prospective cohort study., Setting: Toronto, Ontario, Canada., Participants: Chinese women who were recent immigrants (n = 244), nonrecent immigrants (n = 247), or Canadian born (n = 100)., Methods: Women completed surveys at 1, 3, 6, and 12 months after birth. We measured fatigue with the use of the Multidimensional Assessment of Fatigue scale. Fatigue predictor variables were classified as baseline (e.g., immigrant status) or time varying (e.g., depression). We used latent growth curve modeling to examine fatigue trajectories and identify predictors over time., Results: Fatigue followed a nonlinear pattern: it improved from 1 to 6 months after birth and then worsened from 6 to 12 months after birth. Depression, anxiety, infant sleep characteristics, and breastfeeding problems, but not immigrant status, significantly increased risk for fatigue. Several daily activities were significantly influenced by fatigue, particularly early in the postpartum period as well as later, which showed a U-shaped relationship between fatigue and activities of daily living., Conclusion: Fatigue is common and persistent across the postpartum period. Modifiable risk factors related to mental health, infant sleep, and breastfeeding difficulties suggest that preventive strategies for maternal fatigue warrant further investigation., (Copyright © 2020. Published by Elsevier Inc.)

Background: Decisions about antidepressant use in pregnancy are complex. Little is known about how pregnancy-planning and already pregnant women making these decisions differ., Methods: In 95 Canadian women having difficulty deciding whether to take antidepressants in pregnancy, we compared sociodemographic factors, clinical characteristics, and treatment intent between women planning pregnancy (preconception women) and currently-pregnant women., Results: About 90% of preconception women (n = 55) were married or cohabitating and university-educated, and over 60% had an annual income of > 80,000 CAD/year; this was not different from currently-pregnant women (n = 40). Almost all women had previously used antidepressants, but preconception women were more likely to report current use (85.5% vs. 45.0%). They were more likely to have high decisional conflict (83.6% vs. 60.0%) and less likely to be under the care of a psychiatrist (29.1% vs. 52.5%). Preconception women were more likely than pregnant women to report the intent to use antidepressants (60% vs. 32.5%, odds ratio 3.11, 95% confidence interval 1.33-7.32); this was partially explained by between-group differences in current antidepressant use., Conclusions: Preconception women were more likely than pregnant women to intend to use antidepressants in pregnancy, in part because more of them were already using this treatment. Strategies to enhance support for decision-making about antidepressant medication use in pregnancy may need to be tailored differently for pregnancy-planning and already pregnant women.

Background: Chronic medical conditions (CMCs) and poverty commonly co-occur and, while both have been shown to independently increase the risk of perinatal mental illness, their collective impact has not been examined., Methods: This population-based study included 853 433 Ontario (Canada) women with a singleton live birth and no recent mental healthcare. CMCs were identified using validated algorithms and disease registries, and poverty was ascertained using neighbourhood income quintile. Perinatal mental illness was defined as a healthcare encounter for a mental health or substance use disorder in pregnancy or the first year postpartum. Modified Poisson regression was used to test the independent impacts of CMC and poverty on perinatal mental illness risk, adjusted for covariates, and additive interaction between the two exposures was assessed using the relative excess risk due to interaction (RERI) and synergy index (SI)., Results: CMC and poverty were each independently associated with increased risk of perinatal mental illness (CMC vs no CMC exposure: 19.8% vs 15.6%, adjusted relative risk (aRR) 1.21, 95% CI (CI) 1.20 to 1.23; poverty vs no poverty exposure: 16.7% vs 15.5%, aRR 1.06, 95% CI 1.05 to 1.07). However, measures of additive interaction for the collective impact of both exposures on perinatal mental illness risk were not statistically significant (RERI 0.02, 95% CI -0.01 to 0.06; SI 1.09, 95% CI 0.95 to 1.24)., Conclusion: CMC and poverty are independent risk factors for perinatal mental illness and should be assessed as part of a comprehensive management programme that includes prevention strategies and effective screening and treatment pathways., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: SV receives royalties from UpToDate for authorship of materials related to depression and pregnancy.

Thermometry based on magnetic nanoparticles (MNPs) is an emerging technology that allows for remote temperature measurements throughout a volume that are impossible to achieve using conventional probe-based or optical methods. This metrology is based on the temperature-dependent nature of these particles' magnetization; however, commercially available MNPs generally display insufficient magneto-thermosensitivity for practical use in applications near room temperature. Here we present engineered MNPs based on cobalt-doped ferrites developed for 200 K - 400 K thermometry applications. The synthesis relies on easily scalable solution chemistry routes, and is tunable to afford MNPs of controlled size and composition. These improved nanothermometers form the basis of our effort to develop a practical means for spatially resolved, 3D, high-sensitivity measurements of temperature based on AC magnetometry., Competing Interests: Author’s Statement The authors declare no conflict of interest.

Objective/Background : Our primary objective was to describe and identify predictors of any and predominant bed-sharing at 4 and 12 weeks postpartum among Chinese-Canadian mothers. Participants : We conducted a longitudinal study of 570 Chinese immigrant and Canadian-born women in Toronto, Ontario. Methods : Any bed-sharing, defined as sharing a bed or mattress for any part of the night on any night in the previous week, and predominant bed-sharing, defined as sharing a bed or mattress for most of the night, on more than half the nights of the previous week, were evaluated at 4 and 12 weeks postpartum. Predictors of bed-sharing, evaluated in multivariable logistic regression models, were background (age, parity, education, household size, delivery mode, social support), cultural (immigrant status, acculturative stress, acculturation, postpartum ritual uptake), and postpartum variables (mental health, breastfeeding problems, fatigue, sleep knowledge, plans for bed-sharing, perceptions of infant sleep problems, cognitions about infant sleep). Results : One in five women (20.7%) reported bed-sharing as the predominant sleep location for their infant at 4 weeks postpartum, with nearly half (45.6%) reporting any bed-sharing at this time. The prevalence of any bed-sharing remained relatively stable at 12 weeks postpartum (46.5%), while predominant bed-sharing increased to 30.1%. The most consistent predictors of any and predominant bed-sharing at 4 and 12 weeks postpartum were lower education level, greater acculturative stress, and predelivery plans to bed-share. Conclusions : These findings have implications for the development of clinical recommendations given to expectant and new parents to promote infant sleep practices that are consistent with American Academy of Pediatrics recommendations.

Background: Induced abortion is an indicator of access to, and quality of reproductive healthcare, but rates are relatively unknown in women with schizophrenia., Aims: We examined whether women with schizophrenia experience increased induced abortion compared with those without schizophrenia, and identified factors associated with induced abortion risk., Method: In a population-based, repeated cross-sectional study (2011-2013), we compared women with and without schizophrenia in Ontario, Canada on rates of induced abortions per 1000 women and per 1000 live births. We then followed a longitudinal cohort of women with schizophrenia aged 15-44 years (n = 11 149) from 2011, using modified Poisson regression to identify risk factors for induced abortion., Results: Women with schizophrenia had higher abortion rates than those without schizophrenia in all years (15.5-17.5 v. 12.8-13.6 per 1000 women; largest rate ratio, 1.33; 95% CI 1.16-1.54). They also had higher abortion ratios (592-736 v. 321-341 per 1000 live births; largest rate ratio, 2.25; 95% CI 1.96-2.59). Younger age (<25 years; adjusted relative risk (aRR), 1.84; 95% CI 1.39-2.44), multiparity (aRR 2.17, 95% CI 1.66-2.83), comorbid non-psychotic mental illness (aRR 2.15, 95% CI 1.34-3.46) and substance misuse disorders (aRR 1.85, 95% CI 1.47-2.34) were associated with increased abortion risk., Conclusions: These results demonstrate vulnerability related to reproductive healthcare for women with schizophrenia. Evidence-based interventions to support optimal sexual health, particularly in young women, those with psychiatric and addiction comorbidity, and women who have already had a child, are warranted.

Background: Depression in pregnancy negatively affects maternal-child health. Transcranial direct current stimulation (tDCS), a non-invasive brain stimulation treatment for depression, has not been evaluated in pregnancy., Objective: To conduct a pilot randomized controlled trial (RCT) to evaluate tDCS for antenatal depression., Methods: In this pilot RCT in Toronto, Ontario (October 2014 to December 2016), adult pregnant women 14-32 weeks gestation with major depressive disorder who had declined antidepressant medication were considered for inclusion. Participants were randomly assigned 1:1 to tDCS or sham-control. Active tDCS comprised 30-min sessions of 2 mAmp direct current delivered over the dorsolateral prefrontal cortex, 5 days per week, for 3 weeks. Sham was administered similarly, but with current turned off after 30 s. Main outcomes were feasibility, acceptability, and protocol adherence. Maternal Montgomery Asperg Depression Rating Scale (MADRS) was measured post-treatment and at 4 and 12 weeks postpartum., Results: Of 20 women randomized, 16 completed treatment and provided data (124 tDCS, 122 sham sessions). Views of treatment were positive with no serious adverse events. Post-treatment estimated marginal mean MADRS scores were 11.8 (standard error, SE 2.66) for tDCS and 15.4 (SE 2.51) for sham (p = 0.34). At 4 weeks postpartum, 75.0% of tDCS women were remitted versus 12.5% sham-control (p = 0.04)., Conclusions: Results support proceeding to a definitive RCT to evaluate tDCS for antenatal depression. The preliminary efficacy estimates immediately post-treatment and in the postpartum, are encouraging with respect to the potential use of tDCS to improve treatment rates in this population. The trial was registered at: clinical trials.gov (NCT02116127)., (Copyright © 2019 Elsevier Inc. All rights reserved.)

To systematically review and meta-analyze research investigating the association between maternal anxiety during pregnancy and outcomes for mother and baby following the immediate delivery period. MEDLINE, Medline In-Process & Other Non-Indexed Citations, PsycINFO, Embase, CINAHL, and the Cochrane library were searched. English-language, prospective studies providing data on outcomes following delivery in women with and without antenatal anxiety (defined by clinical diagnosis or score on validated scale) were included. Three-hundred-fifty-eight articles were retrieved and 13 were included. Titles and abstracts were screened; two reviewers independently reviewed full text articles, conducted quality assessments, extracted, and checked the data. Where available for > 2 studies, random effect meta-analysis was conducted and heterogeneity was quantified. Subanalyses explored moderators, regardless of heterogeneity, including type of anxiety assessment and timing, among others. There were two outcomes that were amenable to meta-analysis. Antenatal anxiety was significantly associated with postpartum depression (PPD) measured within 6 months postpartum (pooled odds ratio [OR] = 2.64, 95% CI 2.02-3.46; 8 studies), regardless of restricting analyses to those studies controlling for prenatal depression (2.45, 1.77-3.39; 6 studies). Associations were also significant when PPD was measured at 1-3 months (2.57, 1.94-3.40; 7 studies) and 6-10 months (4.42, 1.45-13.49; 3 studies). Maternal anxiety was also associated with reduced odds of breastfeeding (0.63, 0.53-0.74; 5 studies). Antenatal anxiety is associated with PPD up to the first 10 months, independent of prenatal depression, and with lower odds of breastfeeding.

Aim: Women with schizophrenia are vulnerable to adverse reproductive health outcomes. Short inter-pregnancy interval, or rapid repeat pregnancy, is associated with maternal and infant complications, and may be preventable. Whether women with schizophrenia are at disproportionate risk for rapid repeat pregnancy is unknown., Methods: This population-based cohort study in Ontario, Canada (2002-2013) compared women with and without schizophrenia on their risk of rapid repeat pregnancy, defined as pregnancy within 12 months of an index live birth. Among women with public drug coverage, those with and without schizophrenia were compared on their use of non-barrier contraception (hormonal and surgical) post-delivery., Results: Women with schizophrenia (n = 1565) were at higher risk for rapid repeat pregnancy than women without schizophrenia (n = 924,657) (6.3% vs. 3.9%, adjusted relative risk, aRR 1.31, 95% confidence interval, CI, 1.07-1.59). They had more rapid repeat pregnancies resulting in live births (aRR 1.85, 95% CI 1.26-2.72), but not pregnancy losses (aRR 1.50, 95% CI 0.99-2.29) or induced abortions (aRR 1.07, 95% CI 0.81-1.42). Post-delivery non-barrier contraception use was similar between groups (43.7% vs. 43.6%, aRR 1.06, 95% CI 0.93-1.20), although women with schizophrenia were more likely to use injectable contraception (14.1% vs. 10.1%, aRR 1.67, 95% CI 1.35-2.07)., Discussion: Women with schizophrenia are at higher risk than their peers for rapid repeat pregnancy, but use non-barrier contraception at similar rates. The postnatal period is an opportune time to initiate targeted interventions designed to optimize planning for any future pregnancies, and contribute to improving maternal and child health in this vulnerable group., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: The frenzy of postbirth events often takes a toll on mothers' mental well-being, leaving them susceptible to postpartum psychological disorders such as postnatal depression (PND). Social support has been found to be effective in restoring the emotional well-being of new mothers. Therefore, mothers need to be supported during the crucial postpartum period to buffer the negative after effects of childbirth and to promote healthier maternal well-being., Objective: This study aimed to evaluate the effectiveness of a technology-based peer-support intervention program (PIP) on maternal outcomes during the early postpartum period., Methods: A randomized, parallel-armed controlled trial was conducted. The study recruited 138 mothers (69 in intervention group, 69 in control group) at risk of PND from a tertiary hospital in Singapore. To support these mothers, 20 peer volunteers were recruited by word of mouth and trained by a psychiatrist in social support skills before the intervention commenced. The 4-week-long intervention included a weekly follow-up with a peer volunteer through phone calls or text messages. The intervention group received peer support in addition to the standard care offered by the hospital. The control group only received postnatal standard care. Maternal outcomes (PND, postnatal anxiety [PNA], loneliness, and perceived social support) were measured with reliable and valid instruments. Data were collected immediately postpartum, at 1 month postpartum and at 3 months postpartum. The general linear model was used to compare the groups for postpartum percentage changes in the outcome variables at first and third months, and the linear mixed model was used to compare the trend over the study period., Results: There was a statistically significant difference in Edinburgh Postnatal Depression Scale scores (d=-2.11; 95% CI -4.0 to -0.3; P=.03) between the intervention and control groups at 3 months postpartum after adjusting for covariates. The intervention group had a significant change over time compared with the control group., Conclusions: The technology-based PIP was found to be effective in reducing the risk of PND among new mothers and showed a generally positive trend in reducing PNA and loneliness and increasing perceived social support. This study highlights the importance of training paraprofessionals to provide needed support for new mothers postpartum. A further long-term evaluation of the PIP on maternal and family outcomes and its cost-effectiveness is needed to inform clinical practices., Trial Registration: ISRCTN Registry ISRCTN14864807; https://www.isrctn.com/ISRCTN14864807., International Registered Report Identifier (irrid): RR2-10.2196/resprot.9416., (©Shefaly Shorey, Cornelia Yin Ing Chee, Esperanza Debby Ng, Ying Lau, Cindy-Lee Dennis, Yiong Huak Chan. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 29.08.2019.)

Background: One in 5 women experience mental illness in pregnancy or post partum. Universal preventive interventions have not lowered the incidence of perinatal mental illness, perhaps because those at highest risk were not targeted. Outside of pregnancy, chronic physical conditions are known to confer increased risk for mental illness. Our objective was to examine the association between chronic physical conditions and risk of perinatal mental illness., Methods and Findings: We conducted a population-based retrospective cohort study using linked health administrative data sets in Ontario, Canada, in 2005 to 2015. We compared 77,385 women with chronic physical conditions to 780,619 women without such conditions, all of whom had a singleton live birth. Excluded were women with a mental illness diagnosis within 2 years before pregnancy. Chronic physical conditions were captured using the Agency for Healthcare Research and Quality Chronic Condition Indicator, applied to acute healthcare encounters in the 2 years before pregnancy. The outcome was perinatal mental illness, defined by a mental illness or addiction diagnosis arising between conception and 365 days post partum. The outcome was further defined by timing (prenatal or post partum) and specific diagnosis (psychotic disorder, mood or anxiety disorder, substance use disorder, self-harm, or other). Modified Poisson regression generated relative risks and 95% confidence intervals (CIs), adjusted for age, parity, rural residence, income quintile, and remote history of mental health care. Women in the cohort had an average age of 29.6 years (standard deviation 5.4), 44.2% were primiparous, 11.0% lived in a rural area, 40.1% were in the lowest 2 income quintiles, and 47.9% had a remote history of mental health care. More women with (20.4%) than without (15.6%) a chronic physical condition experienced perinatal mental illness-an adjusted relative risk (aRR) of 1.20 (95% CI 1.18-1.22, p < 0.0001). The aRRs were statistically significant for mental illness in pregnancy (1.12, 95% CI 1.10-1.15, p < 0.0001) and post partum (1.25, 95% CI 1.23-1.28, p < 0.0001). Psychotic disorders (aRR 1.50, 95% CI 1.36-1.65, p < 0.0001), mood or anxiety disorders (aRR 1.19, 95% CI 1.17-1.21, p < 0.0001), substance use disorders (aRR 1.47, 95% CI 1.34-1.62, p < 0.0001), and other mental illness (aRR 1.68, 95% CI 1.50-1.87, p < 0.0001) were more likely in women with than without chronic physical conditions, but not self-harm (aRR 1.14, 95% CI 0.87-1.48, p = 0.34). The study was limited by reliance on acute health care encounters to measure chronic physical conditions and the inability to capture undiagnosed mental health problems., Conclusions: Findings from this study suggest that women with a chronic physical condition predating pregnancy may be at heightened risk of developing mental illness in the perinatal period. These women may require targeted efforts to lower the severity of their condition and improve their coping strategies and supports in pregnancy and thereafter., Competing Interests: We have read the journal’s policy and the authors of this manuscript have the following competing interests: SNV declares royalties from Up to Date Inc. for chapters on depression and antidepressants in pregnancy.

Objective: Support from fathers is consistently associated with improved breastfeeding duration and exclusivity rates. Additionally, there is growing evidence that fathers want to be included in breastfeeding interventions provided by health care professionals. The objective of this review was to determine the effect of partner-inclusive educational and psychosocial interventions on breastfeeding initiation, duration, and exclusivity., Design: A systematic review was conducted using a search strategy developed with an expert health sciences librarian. Electronic databases MEDLINE, EMBASE, CINAHL, and PsycINFO were systematically searched for randomized controlled trials and quasi-experimental studies from inception to August 4, 2018. Independent data extraction and quality assessments were conducted by authors using Cochrane Collaboration tools. Due to significant heterogeneity in intervention content, outcome measures, and follow-up time points, data were synthesized qualitatively., Findings: 3982 articles were identified, of which 12 studies in 15 publications met the inclusion criteria and were included. All of the studies improved at least one breastfeeding outcome, including duration (n = 5/9) and exclusivity (n = 8/10) up to 24 weeks postpartum. Six studies examined increasing paternal breastfeeding support and all found beneficial effects. Biases were identified in the studies with the most common bias relating to the randomization process and the blinding of outcome assessors., Implications for Practice: The inclusion of fathers/partners in breastfeeding interventions improves breastfeeding initiation, duration, and exclusivity rates. Interventions that include face-to-face information delivery, are designed in a culturally appropriate manner, and provide information on how partners can support breastfeeding are more likely to have a beneficial effect. Research is warranted to examine the underlying intervention mechanisms., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: To summarize the effects of antenatal benzodiazepine exposure as monotherapy and in combination with antidepressants on the risk of congenital malformations., Data Sources: MEDLINE, PsycINFO, CINAHL, Embase, and the Cochrane Library were searched from inception to June 30, 2018, using controlled vocabulary and keywords (eg, prenatal, benzodiazepines, malformation)., Study Selection: English-language cohort studies with prospectively collected data on the risk of malformations in benzodiazepine-exposed and -unexposed offspring were evaluated. 23,909 records were screened, 56 studies were assessed for eligibility, and 8 studies were included., Data Extraction: Quality was assessed by 2 independent reviewers and data extracted. Random-effects models were used for outcomes (≥ 3 studies). Subanalyses examined effect of potential moderators including study quality and timing of exposure, among others., Results: Prenatal benzodiazepine use was not associated with an increased risk of congenital malformations (odds ratio [OR] = 1.13; 95% CI, 0.99 to 1.30, 8 studies, n = 222/5,195 exposed and 64,335/2,082,467 unexposed), including with first trimester exposure specifically (OR = 1.08; 95% CI, 0.93 to 1.25, P = .33; 5 studies, n = 181/4,331 exposed and 64,308/2,081,463 unexposed). There was no significant association with cardiac malformation following exposure (OR = 1.27; 95% CI, 0.98 to 1.65, P = .07; 4 studies, n = 61/4,414 exposed and 19,260/2,033,402 unexposed). However, concurrent use of benzodiazepine and antidepressants during pregnancy was associated with a significantly increased risk of congenital malformations (OR = 1.40; 95% CI, 1.09 to 1.80, P = .008; 3 studies)., Conclusions: Benzodiazepine exposure during pregnancy does not appear to be associated with congenital malformations or with cardiac malformations specifically. There may be an increased risk of congenital malformations when benzodiazepines are used in conjunction with antidepressants, suggesting that caution with this combination is warranted., (© Copyright 2019 Physicians Postgraduate Press, Inc.)

Breastfeeding benefits mothers and infants. Although immigration in many regions has increased in the last three decades, it is unknown whether immigrant women have better breastfeeding outcomes than non-immigrants. The aim of this study was to conduct a systematic review and meta-analysis to determine whether breastfeeding rates differ between immigrant and non-immigrant women. We searched Medline, Embase, PsycINFO, CINAHL and Google Scholar, 1950 to 2016. We included peer-reviewed cross-sectional and cohort studies of women aged ≥16 years that assessed and compared breastfeeding rates in immigrant and non-immigrant women. Two independent reviewers extracted data using predefined standard procedures. The analysis included 29 studies representing 1,539,659 women from 14 countries. Immigrant women were more likely than non-immigrants to initiate any (exclusive or partial) breastfeeding (pooled adjusted prevalence ratio 1.13, 95% confidence interval [CI] 1.07-1.19; 11 studies). Exclusive breastfeeding initiation was higher but borderline significant (adjusted prevalence ratio 1.20, 95% CI 1.00-1.45; 5 studies, p = 0.056). Immigrant women were more likely than non-immigrants to continue any breastfeeding between 12- and 24-week postpartum (pooled adjusted risk ratio 2.04, 95% CI 1.79-2.32; 3 studies) and > 24 weeks (adjusted risk ratio 1.33, 95% CI 1.02-1.73; 6 studies) but not exclusive breastfeeding. Immigrant women are more likely than non-immigrants to initiate and maintain any breastfeeding, but exclusive breastfeeding remains a challenge for both immigrants and non-immigrants. Social and cultural factors need to be considered to understand the extent to which immigrant status is an independent predictor of positive breastfeeding practices., (© 2019 John Wiley & Sons Ltd.)

Competing Interests: Competing interests: SV receives royalties from UpToDate Inc for authorship of materials related to depression and pregnancy.

Objective: Preconception health is an important determinant of maternal, paternal, and infant outcomes. Knowledge is commonly used to evaluate the effectiveness of interventions to promote preconception health. Our objective was to examine how preconception health knowledge has been measured in the existing literature and to identify measurement gaps, biases, and logistical challenges., Data Source: MEDLINE, EMBASE, PsycINFO, CINAHL, the Cochrane Database of Systematic Reviews, and gray literature were searched from database inception to January 2018., Study Inclusion and Exclusion Criteria: Studies were included if they measured preconception or interconception health knowledge and included reproductive-aged women and/or men., Data Extraction: Two independent reviewers completed data extraction and quality appraisal using standardized instruments., Data Synthesis: Due to measurement heterogeneity, a narrative synthesis was performed., Results: The review included 34 studies from 14 countries with data collected in 2000 to 2017. Most studies used cross-sectional (n = 24) or prepost designs (n = 7). Studies primarily sampled women (n = 25), and methodological quality was rated largely as weak (n = 18) or moderate (n = 14). Preconception health knowledge tools focused on fertility, folic acid, and alcohol, with few questions pertaining to men's health, mental health, or the interconception period. Only 19 (56%) studies reported psychometric properties of their knowledge tools., Conclusions: This systematic review revealed the need for a valid and reliable knowledge tool that reflects a holistic conceptualization of preconception health.

Background: Sleep disruption during the first postpartum year is associated with several negative health outcomes including postpartum depression. Such disruption may be a greater issue for parents of preterm neonates, yet literature on this subject has not been critically reviewed., Objective: To synthesize literature on sleep quantity, sleep quality, and factors influencing sleep among parents of preterm infants during infant hospitalization and following discharge., Design: A systematic review., Data Sources: Medline, EMBASE, CINAHL, PsycINFO, Scopus, and Cochrane Database of Systematic Reviews were searched from their inception to February 2017., Methods: Potentially eligible citations were reviewed by two independent reviewers. Both quantitative and qualitative studies were eligible for inclusion. Data on eligible studies and review outcomes were extracted using a customized form., Findings: Eighteen reports from 16 studies met inclusion criteria. Four studies included a control group of parents of full-term infants. Three studies reported sleep quantity means, of which only one provided values for an exclusive sample of mothers of preterm infants and found on average, mothers obtained 6.3 h of sleep/day in the first 5-10 days. Twelve studies reported on sleep quality; most (n = 10) relied on self-reported measures and identified poor subjective sleep quality whereas two studies objectively measured sleep of poor quality. Parental stress was the most consistent factor associated with sleep quality., Conclusion and Implications: Quality and quantity of sleep among parents of preterm infants is inadequate and may negatively influence family health outcomes. Further research on correlates and changes in sleep is required to identify at-risk parents and inform targeted clinical recommendations and interventions aimed at maximizing sleep for parents of preterm infants., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Decisions about antidepressant use in pregnancy are complex. We performed a pilot randomized controlled trial assessing the feasibility of a trial protocol for an online patient decision aid (PDA) for women deciding about antidepressant use in pregnancy., Methods: 96 preconception and pregnant Canadian women recruited from specialist (n = 51) and non-specialist (n = 45) settings with Decisional Conflict Scale (DCS, range 0-100) score of ≥25 signifying moderate-to-high decisional conflict were randomly allocated to either the PDA or a control condition that guided participants to publicly available resources for advice around antidepressants and pregnancy. Follow-up data were collected at 4 weeks post-randomization., Results: About 88.9% of eligible participants consented to participate. Women's views of the tool were positive; 88.7% of participants provided follow-up data. At follow-up, mean DCS score had decreased by 19.9 points in the PDA group vs. 13.3 in controls (adjusted mean difference, MD, 7.01, 95% CI -14.3 to 0.30). In the non-specialist setting, DCS scores decreased more for PDA users (25.5 points) than controls (10.5 points; adjusted MD -15.1, 95% CI -25.6 to -4.55); the MD was negligible in the specialist setting., Limitations: The main limitation is the highly educated, high-income nature of our sample., Conclusions: Evaluation of an online PDA for antidepressant use in pregnancy with national recruitment is feasible. Pilot results suggest that the tool is acceptable and reduces decisional conflict more than clinical care alone in a non-specialist setting. Evaluation of the PDA's impact on longer-term maternal and child clinical outcomes is a key next step., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Intentional injury, including suicide and assault, is a leading cause of maternal morbidity and mortality. We aimed to determine whether immigrant and nonimmigrant women differ in their 1-year risk of intentional injury after birth., Methods: This population-based retrospective cohort study used administrative data from Ontario from 2002 to 2012. Risk of self-inflicted injury (self-harm or suicide), and injury inflicted by others (assault or homicide), were each analyzed within 1 year after delivery of a live-born infant for immigrant and nonimmigrant mothers. Relative risks (RRs) were adjusted for maternal age, parity, income, resource utilization and psychiatric history., Results: The study included 327 279 immigrant and 942 502 nonimmigrant mothers. Risk of self-inflicted injury was similar among immigrants and nonimmigrants (adjusted RR 0.91, 95% confidence interval [CI] 0.78-1.04), with no variation by duration of residence or refugee status. Immigrants were at lower risk than nonimmigrants for injury inflicted by others (adjusted RR 0.57, 95% CI 0.51-0.64); that risk was higher among refugees than among nonrefugee immigrants (adjusted RR 1.79, 95% CI 1.33-2.41), and it was higher among long-term (adjusted RR 2.27, 95% CI 1.76-2.91) and medium-term (adjusted RR 1.58, 95% CI 1.19-2.11) immigrants than among recent immigrants. Variability by country of origin was observed for both injury types., Interpretation: Immigrant mothers have a reported risk for self-inflicted injury after birth similar to that of their Canadian-born counterparts. The extent to which selective underreporting of intentional injury in immigrant women might explain our findings is a key consideration for future research., Competing Interests: Competing interests: Sophie Grigoriadis reports royalties from Psychotherapy Essentials To Go, UpToDate and the Compendium of Therapeutic Choices outside the submitted work and personal fees from Allergan, Eli Lilly, Sage and Pfizer outside the submitted work. No other competing interests were declared., (Copyright 2019, Joule Inc. or its licensors.)

Breastfeeding is the optimal method for infant feeding, yet migrant women may be at risk for suboptimal exclusivity rates. In a cohort of immigrant and Canadian-born Chinese women, our objectives were to (a) describe patterns and prevalence of exclusive breastfeeding at 1, 3, and 6 months postpartum; (b) identify risk and protective factors associated with exclusivity; and (c) examine potentially differential importance of these factors across this 6-month period. This was a prospective study of 565 immigrants and Canadian-born Chinese women (Toronto, Canada). Exclusive breastfeeding was measured at 1, 3, and 6 months postpartum. Predictors comprised fixed (demographics, history of depression, immigrant status, prenatal breastfeeding classes, in-hospital formula supplementation, baseline social support, and baseline acculturative stress) and time-dependent (depression, anxiety, fatigue, and breastfeeding problems) variables. Descriptive statistics, logistic regression, and generalized linear mixed models, respectively, were undertaken to address the objectives. Patterns of breastfeeding practices included exclusive breastfeeding in all time points (26.8%) or none (32.9%) and moving from exclusive to nonexclusive (20.3%) or nonexclusive to exclusive breastfeeding (15.2%). Women less likely to breastfeed exclusively at 1, 3, or 6 months were those whose infants received in-hospital formula supplementation. Exclusivity attrition was higher between 3 and 6 months than 1-3 months. Immigrant status and in-hospital formula supplementation had a significant impact on exclusivity earlier in the postpartum period while breastfeeding problems were associated with decreased exclusivity across time. Proactive preventive efforts are need to maintain breastfeeding exclusivity especially between 3 and 6 months if women are to meet international breastfeeding recommendations., (© 2018 John Wiley & Sons Ltd.)

Background: Breastfeeding rates are suboptimal internationally, and many infants are not receiving any breast milk at all by six months of age. Few interventions increase breastfeeding duration, particularly where there is relatively high initiation. The effect of proactive peer (mother-to-mother) support has been found to increase breastfeeding in some contexts but not others, but if it is shown to be effective would be a potentially sustainable model in many settings. We aimed to determine whether proactive telephone-based peer support during the postnatal period increases the proportion of infants being breastfed at six months of age., Methods: RUBY (Ringing Up about Breastfeeding earlY) was a multicentre, two-arm un-blinded randomised controlled trial conducted in three hospitals in Victoria, Australia. First-time mothers intending to breastfeed were recruited after birth and prior to hospital discharge, and randomly assigned (1:1) to usual care or usual care plus proactive telephone-based breastfeeding support from a trained peer volunteer for up to six months postpartum. A computerised random number program generated block sizes of four or six distributed randomly, with stratification by site. Research midwives were masked to block size, but masking of allocation was not possible. The primary outcome was the proportion of infants receiving any breast milk at six months of age. Analyses were by intention to treat; data were collected and analysed masked to group. The trial is registered with ACTRN, number 12612001024831., Findings: Women were recruited between Feb 14, 2013 and Dec 15, 2015 and randomly assigned to peer support ( n  = 574) or usual care ( n  = 578). Five were not in the primary analysis [5 post-randomisation exclusions]. Infants of women allocated to telephone-based peer support were more likely than those allocated to usual care to be receiving breast milk at six months of age (intervention 75%, usual care 69%; Adj. RR 1·10; 95% CI 1·02, 1·18). There were no adverse events., Interpretation: Providing first time mothers with telephone-based support from a peer with at least six months personal breastfeeding experience is an effective intervention for increasing breastfeeding maintenance in settings with high breastfeeding initiation., Funding: The Felton Bequest, Australia, philanthropic donation and La Trobe University grant.

Background: Increasing the prevalence of optimal breastfeeding practices, including exclusive breastfeeding for 6 months, could prevent an estimated 823,000 child deaths annually. Self-efficacy is an important determinant of breastfeeding behaviors. However, existing measures do not specifically assess exclusive breastfeeding self-efficacy, but rather self-efficacy for any breastfeeding. Hence, we sought to adapt and validate an instrument to measure exclusive breastfeeding self-efficacy., Methods: We modified and added items from Dennis' Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF). It was then implemented in an observational cohort in Gulu, Uganda at 1 (n = 239) and 3 (n = 238) months postpartum ( clinicaltrials.gov NCT02925429). We performed inter-item and adjusted item-test correlations, as well as exploratory factor analysis and parallel analysis at 1 month postpartum to remove redundant items and determine their latent factor structure. We further applied confirmatory factor analysis to test dimensionality of the scale at 3 months postpartum. We then assessed the reliability of the scale and conducted tests of predictive and discriminant validity. Known group comparisons were made by primiparous status and correct breastfeeding knowledge., Results: The modification of the original BSES-SF to target exclusive breastfeeding produced 19 items, which were reduced to 9 based on item correlations and factor loadings. Two dimensions of the adapted scale, the Breastfeeding Self-Efficacy Scale to Measure Exclusive Breastfeeding BSES-EBF emerged: Cognitive and Functional subscales, with alpha coefficients of 0.85 and 0.79 at 3 months postpartum. Predictive and discriminant validity and known group comparisons assessments supported its validity., Conclusions: This version of the Breastfeeding Self-Efficacy scale, the BSES-EBF Scale, is valid and reliable for measuring exclusive breastfeeding self-efficacy in northern Uganda, and ready for adaptation and validation for clinical and programmatic use elsewhere.

We report here on the reproducibility of measurements on a second-order gradiometer superconducting quantum interference device magnetometer of two different yttrium iron garnet spheres, both having a diameter of 1 mm: 1) the National Institute of Standards and Technology magnetic moment standard reference material (SRM) and 2) a commercial sample. It has been suggested that rotating the sample rod around its axis can move the sample center toward the center of the second-order gradiometer coil. The observed value of the magnetic moment will be theoretically a minimum when the radial offset is 0, and this value will increase in a "quadratic" manner with the radial offset. When the magnetic moment of the SRM was repeatedly measured as a function of rotation angle φ from 0° to 360°, we observed a sinusoidal variation in the measured values. The radial offset dependence of the observed magnetic moment was experimentally confirmed by the measurements of the commercial sphere placed in a hole in several cylindrical containers, wherein the distance between the center of the hole and the center of the container was r . The r -dependence of the minimum from each φ -dependent measurement series is qualitatively consistent with the theoretical curve. When the φ -dependent measurements for the SRM in a capsule were repeated 12× over 21 months, the relative standard deviation of the minimums improved up to 0.1%. Knowledge of these facts will be necessary for the accurate measurement of the magnetic moment of other sample forms (e.g., powders).

Technologically relevant magnetic nanoparticles for biomedicine are rarely noninteracting single-domain nanoparticles; instead, they are often interacting, with complex physical and magnetic structures. In this paper, we present both experimental and simulated magnetic hysteresis loops of a system of magnetic nanoparticles with significant interparticle interactions and a well-defined intraparticle structure which are used for magnetic nanoparticle hyperthermia cancer treatment. Experimental measurements were made at 11 K on suspensions of magnetic nanoparticles dispersed in H 2 O which have been frozen in a range of applied magnetic fields to tune the interparticle interactions. Micromagnetic simulations of hysteresis loops investigated the roles of particle orientation with respect to the field and of particle chaining in the shape of the hysteresis loops. In addition, we present an analysis of the magnetic anisotropy arising from the combination of magnetocrystalline and shape anisotropy, given the well-defined internal structure of the nanoparticles. We find that the shape of the experimental hysteresis loops can be explained by the internal magnetic structure, modified by the effects of interparticle interactions from chaining.

Aims: The aim of this study was to evaluate the efficacy of interventions to support coparenting, how partners relate to and support one another as parents, on paternal outcomes., Background: Despite societal shifts in gender roles leading to fathers' increasing involvement in parenting and growing recognition of the need for couples-based parenting interventions, fathers have been underrepresented in parenting research., Design: Systematic review., Data Sources: Medline, Embase, Healthstar, and PsycInfo., Review Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify peer-reviewed articles published up to 2016 that evaluated the effectiveness of coparenting interventions for expectant fathers or fathers of children <18 years. Study quality was assessed using Cochrane risk of bias criteria for Effective Practice and Organisation of Care reviews; Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria were used to summarize quality of the evidence. The primary outcome was coparenting behaviour among men., Results: We identified 16 randomized controlled trials that evaluated 14 coparenting interventions. Nine interventions targeted partners in the perinatal period; five targeted parents of children. All but one involved face-to-face contact, but this varied in duration and intensity. Of the 12 trials that examined coparenting outcomes, eight reported an effect on at least one measure of paternal coparenting behaviour. The quality of the evidence was at a low level., Conclusion: Success was moderate, supporting the need for future research to explore the use of additional approaches to increase efficacy, including technology-based interventions, to improve uptake among men., (© 2018 John Wiley & Sons Ltd.)

This study sought to determine the level of interest in online peer support among infertility patients, factors associated with such interest, and preferences for features of an online peer support network. A sample of 236 men and 283 women ( n  = 519) seeking fertility treatment were recruited from four clinics in Ontario and Quebec, Canada. Participants completed an anonymous online questionnaire assessing demographics, perceived stress and fertility characteristics, in addition to interest in and preferences for online infertility peer support. Most men (80.1%) and women (89.8%) expressed interest in online peer support, with perceived stress being related to interest among both men and women. Non-White ethnicity and lower income were related to greater interest among men. Patients reported a preference for mobile accessibility, monitored peer-to-peer communication, and links to information. Men and women, particularly those with high levels of perceived stress, expressed interest in online peer support and shared similar preferences for features irrespective of fertility characteristics. Demographic characteristics and perceived stress were related to a desire for more personalized support options.

Background: Childcare stress has been shown to predict postpartum depression; however, there is little research exploring and validating the dimensions of childcare stress instruments such that preventive interventions can be created., Objectives: The aim of this study was to develop and psychometrically test an instrument to measure parental perceptions of postpartum childcare stress., Methods: Using research based on postpartum stress and childcare stress, the Postpartum Childcare Stress Checklist (PCSC) was developed, and content validity was judged by experts. The PCSC was psychometrically assessed in a cohort of 541 women in a health region near Vancouver, Canada, who were followed to 8 weeks postpartum in 2002. The psychometric assessment analyses comprised internal consistency, exploratory factory analysis, concurrent validity, and predictive validity., Results: The 19-item PCSC had good internal consistency (Kuder-Richardson Formula 20 coefficient: 0.81). Exploratory factor analysis revealed the following dimensions: (a) relationship with the partner, (b) caring for the infant, (c) maternal social interactions, and (d) establishing a new routine. Predictive validity analyses showed that PCSC total and subscale scores at 4 weeks were positively correlated with depressive symptomatology, anxiety, and perceived stress and negatively correlated with global and partner support at 8 weeks postpartum., Discussion: The PCSC is a measure of childcare stress with excellent reliability and validity. Upon further testing, it may be used to identify women and couples in need of greater support, individualize postpartum care, and evaluate the effectiveness of preventive interventions.

Background: The Breastfeeding Self-Efficacy Scale-Short Form is a reliable instrument to measure mother's confidence in her ability to breastfeed. The Breastfeeding Self-Efficacy Scale-Short Form has traditionally been used postnatally, but evidence suggests that it can be used antenatally to identify mothers at-risk of requiring additional support to improve breastfeeding outcomes., Objective: The aim of this study was to examine the psychometric characteristics of an antenatal version of the Breastfeeding Self-Efficacy Scale-Short Form, among pregnant Portuguese women., Design: Methodological prospective study to examine the psychometric characteristics of the antenatal Portuguese version of the Breastfeeding Self-Efficacy Scale-Short Form., Settings: Two public hospital units in the Northern Portugal., Participants: The sample was comprised of 373 pregnant women recruited at 30-34 gestational weeks., Methods: The original English version of the antenatal Breastfeeding Self-Efficacy Scale-Short Form was translated into Portuguese and the Portuguese antenatal version of the scale was tested in a sample of 373 pregnant women. To examine the psychometric characteristics of the Portuguese antenatal version of the scale, the maternal demographic variables and the depressive and anxiety symptomatology of the participants were examined. The predictive validity of the Portuguese antenatal version of the scale was studied according to infant feeding method at one, three, and six months postpartum., Results: The Cronbach's alpha coefficient was 0.92. The antenatal version of the Breastfeeding Self-Efficacy Scale-Short Form scores were found to be associated with women's parity, educational level, occupational status, time they intend to breastfeed, and previous breastfeeding experience. Also, the antenatal version of the Breastfeeding Self-Efficacy Scale-Short Form scores significantly predicted exclusive breastfeeding at 1 month postpartum., Conclusions: Results provided evidence that the antenatal Portuguese version of the Breastfeeding Self-Efficacy Scale-Short Form is a valid and reliable measure to assess breastfeeding self-efficacy in pregnant women. The antenatal version of the Breastfeeding Self-Efficacy Scale-Short Form could be a useful tool to assist Portuguese health professionals during routine prenatal care appointments to screen women with lower antenatal breastfeeding self-efficacy and, consequently, those that could be at risk for not initiating or early breastfeeding cessation., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: This systematic review and meta-analysis examined the association between maternal antenatal anxiety (AA) and a range of perinatal outcomes., Data Sources: Ovid MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, PsycINFO, CINAHL, Embase, and the Cochrane Library were searched to May 31, 2016, using controlled vocabulary and keywords (eg, prenatal, anxiety, preterm)., Study Selection: Perinatal outcomes of women with and without AA (diagnosed or self-reported using validated scale) derived from English language, prospectively collected data were included. 1,458 abstracts were reviewed, 306 articles were retrieved, and 29 articles were included., Data Extraction: Two independent reviewers extracted data and assessed quality. Random-effects models were utilized for outcomes (≥ 3 studies). Subanalyses examined potential effect moderators including study quality and diagnostic versus self-reported anxiety among others., Results: Antenatal anxiety was associated with increased odds for preterm birth (pooled odds ratio [OR] = 1.54; 95% confidence interval [CI], 1.39 to 1.70, 16 studies) and spontaneous preterm birth (OR = 1.41; 95% CI, 1.13 to 1.75), lower mean birth weight (mean difference = -55.96 g; 95% CI, -93.62 to -18.31 g), increased odds for low birth weight (OR = 1.80; 95% CI, 1.48 to 2.18), earlier gestational age (mean difference = -0.13 wk; 95% CI, -0.22 to -0.04 wk), increased odds for being small for gestational age (OR = 1.48; 95% CI, 1.26 to 1.74), and smaller head circumference (mean difference = -0.25 cm; 95% CI, -0.45 to -0.06 cm). Heterogeneity between studies was not significant for most outcomes. Subanalyses for birth weight found women with diagnosed anxiety had infants with significantly lower birth weight (P < .03) compared to those identified with rating scales (although both subanalyses were significant [P < .01]). Associations between anxiety and preeclampsia, cesarean delivery, and Apgar scores were nonsignificant., Conclusions: Antenatal anxiety is associated with multiple adverse perinatal outcomes and is not benign. The impact of treating anxiety on these associations is unknown., (© Copyright 2018 Physicians Postgraduate Press, Inc.)