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To evaluate the effects of early pregnancy loss on subsequent health care use and costs.Linked administrative health databases from Manitoba, Canada.This was a population-based cohort study. The exposure of interest was first recorded ectopic pregnancy or miscarriage (EPM). Outcomes included visits to all ambulatory care providers, family physicians (FPs), specialists, and hospitals, as well as the costs associated with these visits. We also assessed the impact of EPM on a global measure of health service utilization and the incidence and costs of psychotropic medications.We identified women who experienced their first recorded loss (EPM) from 2003-2012 and created a propensity score model to match these women to women who experienced a live birth, with outcome measures available through 31 December 2014. We used a difference in differences approach with multivariable negative binomial models and generalized estimating equations (GEE) to assess the impact of EPM on the aforementioned health care utilization indicators.EPM was associated with a short-term increase in visits to, and costs associated with, certain ambulatory care providers. These findings were driven in large part by increased visits/costs to FPs (rate difference [RD]: $19.92 [95% CI: $16.33, $23.51]) and obstetrician-gynecologists (OB-GYNs) (RD $9.41 [95% CI: $8.42, $10.40]) in the year immediately following the loss, excluding care associated with the loss itself. We also detected an increase in hospital stays and costs and a decrease in the use of psychotropic medications relative to matched controls.Pregnancy loss may lead to subsequent increases in certain types of health care utilization. While the absolute costs associated with post-EPM care are relatively small, the observed patterns of service utilization are informative for providers and policy makers seeking to support women following a loss.

To identify determinants of cesarean delivery (CD) and examine associations between mode of delivery (MOD) and maternal and perinatal outcomes.We conducted a retrospective analysis of a Canadian multicentre birth cohort derived from provincial data collected in 2008/2009. Maternal and perinatal characteristics and outcomes were compared between vaginal and cesarean birth and between the following MOD subgroups: spontaneous vaginal delivery (VD), assisted VD, planned cesarean delivery (CD), and intrapartum CD. Multivariate regression identified determinants of CD and the effects of MOD and previous CD on maternal and perinatal outcomes.The cohort included 264 755 births (72.1% VD and 27.9% CD) from 91 participating institutions. Determinants of CD included maternal age, parity, previous CD, chronic hypertension, diabetes, urinary tract infection or pyelonephritis, gestational hypertension, vaginal bleeding, labour induction, pre-term gestational age, low birth weight, large for gestational age, malpresentation, and male sex. CD was associated with greater risk of maternal and perinatal morbidity and mortality. Subgroup analysis demonstrated higher risk of adverse pregnancy outcomes with assisted VD and intrapartum CD than spontaneous VD. Planned CD reduced the risk of obstetric wound hematoma and perinatal mortality but increased maternal and neonatal morbidity. Previous CD increased the risk of maternal and neonatal morbidity among multiparous women.The CD rate in Canada is consistent with global trends reflecting demographic and obstetric intervention factors. The risk of adverse pregnancy outcomes with CD warrants evaluation of interventions to safely prevent nonessential cesarean birth.

Prenatal care is a vital and important part of a healthy pregnancy, providing many maternal and health benefits. Despite Canada’s publically funded health care system with universal access, inadequate rates of prenatal care continue to be observed. As a modifiable risk factor, the process variables that influence satisfaction with prenatal care in Canadian settings have received little attention. The objective of this study was to identify the predictors of satisfaction with prenatal care. A cross-sectional, descriptive, correlational design was used to examine the relationships between expectations, interpersonal processes of care, the quality of prenatal care, personal characteristics, and the type of provider with overall satisfaction, and with four dimensions of satisfaction. A convenience sample of 216 pregnant women was surveyed using self-administered questionnaires with women in their third trimester. Multiple linear regression analyses were used to identify predictors of satisfaction. The quality of prenatal care and provider interpersonal style together explained 80% of the variance in overall satisfaction. Patient-centered decision-making was a significant predictor of satisfaction with information, while having a midwife was a predictor of satisfaction with system characteristics. Expectations were not related to satisfaction. Improving quality of care, provider interpersonal style and patient-centered decision making, and improving the structural characteristics of prenatal care may be effective in improving women’s satisfaction and utilization of prenatal care.

Background Pregnancy loss is common and several factors (e.g. chromosomal anomalies, parental age) are known to increase the risk of occurrence. However, much existing research focuses on recurrent loss; comparatively little is known about the predictors of a first miscarriage. Our objective was to estimate the population-level prevalence of miscarriages and to assess the contributions of clinical, social, and health care use factors as predictors of the first detected occurrence of these losses. Methods In this population-based cohort study, we used linked administrative health data to estimate annual rates of miscarriage in the Manitoba population from 2003 to 2014, as a share of identified pregnancies. We compared the unadjusted associations between clinical, social, and health care use factors and first detected miscarriage compared with a live birth. We estimated multivariable generalized linear models to assess whether risk factors were associated with first detected miscarriage controlling for other predictors. Results We estimated an average annual miscarriage rate of 11.3%. In our final sample (n = 79,978 women), the fully-adjusted model indicated that use of infertility drugs was associated with a 4 percentage point higher risk of miscarriage (95% CI 0.02, 0.06) and a past suicide attempt with a 3 percentage point higher risk (95% CI -0.002, 0.07). Women with high morbidity were twice as likely to experience a miscarriage compared to women with low morbidity (RD = 0.12, 95% CI 0.09, 0.15). Women on income assistance had a 3 percentage point lower risk (95% CI -0.04, -0.02). Conclusions We estimate that 1 in 9 pregnant women in Manitoba experience and seek care for a miscarriage. After adjusting for clinical factors, past health care use and morbidity contribute important additional information about the risk of first detected miscarriage. Social factors may also be informative.

Background Repeat caesarean sections (CSs) are major contributors to the high rate of CS in Canada and globally. Women’s decisions to have a planned repeat CS (PRCS) or a trial of labour after CS (TOLAC) are influenced by their maternity care providers. This study explored factors maternity care providers consider when counselling pregnant women with a previous CS, eligible for a TOLAC, about delivery method. Methods A qualitative descriptive design was implemented. Semi-structured, one-to-one in-depth telephone interviews were conducted with 39 maternity care providers in Ontario, Canada. Participants were recruited at 2 maternity care conferences and with the use of snowball sampling. Interviews were audio recorded and transcribed verbatim. Data were uploaded into the data management software, NVIVO 10.0 and analyzed using qualitative content analysis. Results Participants consisted of 12 obstetricians, 13 family physicians and 14 midwives. Emergent themes, reflecting the factors maternity care providers considered when counselling on mode of delivery, were organized under the categories clinical/patient factors, health system factors and provider preferences. Maternity care providers considered clinical/patient factors, including women’s choice … with conditions, their assessment of women’s chances of a successful TOLAC, their perception of women’s risk tolerance, women’s preferred delivery method, and their perception of women’s beliefs and attitudes about childbirth. Additionally, providers considered health system factors which included colleague support for TOLAC and time needed to mount an emergency CS. Finally, provider factors emerged as considerations when counselling. They included provider preference for PRCS or TOLAC, provider scope of practice, financial incentives and convenience related to PRCS, past experiences with TOLAC and PRCS and providers’ perspectives on risk of TOLAC. Conclusion The findings highlight the multiplicity of factors maternity care providers consider when counselling women. Effectively addressing clinical, health care system and personal factors that influence counselling may help decrease non-medically indicated PRCS.

Objective The Manitoba Infant Feeding Database (MIFD) is being piloted as a surveillance system leveraging infant vaccination visits as a point of contact to collect infant feeding data during the first year of life. The objective of this study was to assess data quality and acceptability of the MIFD as a sustainable population-based surveillance system. Methods Internal completeness and internal validity were measured to assess data quality. Internal completeness was defined as the number of completed data fields out of the total number of data fields. Internal validity was defined as the proportion of translation errors from one level of the system, the paper questionnaire, to the next, the electronic database. A survey assessed staff’s acceptance of data collection and submission processes. Results A total of 947 records were reviewed. Data were 98.5% complete. Discrepancies were noted in 13.5% of data. The survey response rate was 78.4%. Nearly all respondents reported that the MIFD data collection tool was easy to use (96.6% agreed or strongly agreed). Whereas some challenges were identified, the majority were willing to continue with the MIFD data collection tool and process (93.1%). Conclusion Results from this evaluation suggest that the MIFD data collection process worked well; however, data validation will require human resources. The MIFD approach provides a sustainable mechanism for collecting data on infant feeding for surveillance and research purposes.

Background Ensuring high quality and equitable maternity services is important to promote positive pregnancy outcomes. Despite a universal health care system, previous research shows neighborhood-level inequities in utilization of prenatal care in Manitoba, Canada. The purpose of this population-based retrospective cohort study was to describe prenatal care utilization among women giving birth in Manitoba, and to determine individual-level factors associated with inadequate prenatal care. Methods We studied women giving birth in Manitoba from 2004/05–2008/09 using data from a repository of de-identified administrative databases at the Manitoba Centre for Health Policy. The proportion of women receiving inadequate prenatal care was calculated using a utilization index. Multivariable logistic regressions were used to identify factors associated with inadequate prenatal care for the population, and for a subset with more detailed risk information. Results Overall, 11.5% of women in Manitoba received inadequate, 51.0% intermediate, 33.3% adequate, and 4.1% intensive prenatal care (N = 68,132). Factors associated with inadequate prenatal care in the population-based model (N = 64,166) included northern or rural residence, young maternal age (at current and first birth), lone parent, parity 4 or more, short inter-pregnancy interval, receiving income assistance, and living in a low-income neighborhood. Medical conditions such as multiple birth, hypertensive disorders, antepartum hemorrhage, diabetes, and prenatal psychological distress were associated with lower odds of inadequate prenatal care. In the subset model (N = 55,048), the previous factors remained significant, with additional factors being maternal education less than high school, social isolation, and prenatal smoking, alcohol, and/or illicit drug use. Conclusion The rate of inadequate prenatal care in Manitoba ranged from 10.5–12.5%, and increased significantly over the study period. Factors associated with inadequate prenatal care included geographic, demographic, socioeconomic, and pregnancy-related factors. Rates of inadequate prenatal care varied across geographic regions, indicating persistent inequities in use of prenatal care. Inadequate prenatal care was associated with several individual indicators of social disadvantage, such as low income, education less than high school, and social isolation. These findings can inform policy makers and program planners about regions and populations most at-risk for inadequate prenatal care and assist with development of initiatives to reduce inequities in utilization of prenatal care.

OBJECTIVE Type 2 diabetes is increasing in children worldwide, with Canadian First Nations (FN) children disproportionally affected. The prevalence of gestational diabetes mellitus (GDM) also is increasing. The objective of this study was to evaluate the impact of GDM exposure in utero and FN status on the subsequent risk of type 2 diabetes in offspring in the first 30 years of life. RESEARCH DESIGN AND METHODS In this population-based historical prospective cohort study, we used administrative databases linked to a clinical database to explore the independent association and interaction between GDM and FN status on the subsequent development of type 2 diabetes in offspring. RESULTS Among 321,008 births with a median follow-up of 15.1 years, both maternal GDM and FN status were independently associated with subsequent risk of type 2 diabetes in offspring in the first 30 years of life (hazard ratio 3.03 [95% CI 2.44–3.76; P < 0.0001] vs. 4.86 [95% CI 4.08–5.79; P < 0.0001], respectively). No interaction between GDM and FN status on type 2 diabetes risk was observed. FN status had a stronger impact on the development of type 2 diabetes in offspring than GDM. CONCLUSIONS GDM is an important modifiable risk factor for type 2 diabetes, and its prevention may reduce the prevalence of subsequent type 2 diabetes in offspring. This study adds unique and rigorous evidence to the global public health debate about the impact of GDM on the long-term health of offspring.

Background Over the past 30 years, the prevalence of diabetes has steadily increased among Canadians, and is particularly evident among First Nations (FN) women. The interplay between FN ancestry, gestational diabetes and the development of subsequent diabetes among mothers remains unclear. Methods After excluding known pre-existing diabetes, we explored whether FN ancestry may modify the association between gestational diabetes and post-partum diabetes among women in Manitoba (1981–2011) via a historical prospective cohort database study. We analysed administrative data in the Population Health Research Data Repository using Kaplan–Meier survival analysis and Cox proportional hazards regression. Results Gestational diabetes was diagnosed in 11 906 of 404 736 deliveries (2.9%), 6.7% of FN and 2.2% of non-FN pregnant women (P < 0.0001). Post-partum diabetes during ≤ 30 years follow-up was more than three times higher among FN women than among non-FN women (P < 0.0001). Diabetes developed in 76.0% of FN and 56.2% of non-FN women with gestational diabetes within the follow-up period. The hazard ratio of gestational diabetes for post-partum diabetes was 10.6 among non-FN women and 5.4 among FN women. Other factors associated with a higher risk of diabetes included lower family income among FN and non-FN women and rural/remote residences among FN women. Among non-FN women, urban residence was associated with a higher risk of diabetes. Conclusion Gestational diabetes increases post-partum diabetes in FN and non-FN women. FN women had substantially more gestational diabetes or post-partum diabetes than non-FN women, partially due to socio-economic and environmental barriers. Reductions in gestational diabetes and socio-economic inequalities are required to prevent diabetes in women, particularly in FN population.

Objective Little is known about how prenatal care influences health outcomes in Canada. The objective of this study was to examine the association of prenatal care utilization with maternal, fetal, and infant outcomes in Manitoba. Methods This retrospective cohort study conducted at the Manitoba Centre for Health Policy investigated all deliveries of singleton births from 2004-2005 to 2008-2009 (N = 67 076). The proportion of women receiving inadequate, intermediate/adequate, and intensive prenatal care was calculated. Multivariable logistic regression was used to examine the association of inadequate and intensive prenatal care with maternal and fetal-infant health outcomes, health care use, and maternal health-related behaviours. Results The distribution of prenatal care utilization was 11.6% inadequate, 84.4% intermediate/adequate, and 4.0% intensive. After adjusting for sociodemographic factors and maternal health conditions, inadequate prenatal care was associated with increased odds of stillbirth, preterm birth, low birth weight, small for gestational age (SGA), admission to the NICU, postpartum depressive/anxiety disorders, and short interpregnancy interval to next birth. Women with inadequate prenatal care had reduced odds of initiating breastfeeding or having their infant immunized. Intensive prenatal care was associated with reduced odds of stillbirth, preterm birth, and low birth weight and increased odds of postpartum depressive/anxiety disorders, initiation of breastfeeding, and infant immunization. Conclusion Inadequate prenatal care was associated with increased odds of several adverse pregnancy outcomes and lower likelihood of health-related behaviours, whereas intensive prenatal care was associated with reduced odds of some adverse pregnancy outcomes and higher likelihood of health-related behaviours. Ensuring women receive adequate prenatal care may improve pregnancy outcomes.

Introduction The process of mental health screening can influence disclosure, uptake of referral, and treatment; however, no studies have explored pregnant women's views of methods of mental health screening. The objectives of this study are to determine pregnant women's comfort and preferences regarding mental health screening. Methods Pregnant women were recruited (May–December 2013) for this cross-sectional descriptive survey from prenatal classes and maternity clinics in Alberta, Canada, if they were aged >16 years and spoke/read English. Descriptive statistics summarized acceptability of screening, and multivariable logistic regression identified factors associated with women's comfort with screening methods. Analysis was conducted in January–December 2014. Results The participation rate was 92% (N=460/500). Overall, 97.6% of women reported that they were very (74.8%) or somewhat (22.8%) comfortable with mental health screening in pregnancy. Women were most comfortable with completing paper- (>90%) and computer-based (>82%) screening in a clinic or at home, with fewest reporting comfort with telephone-based screening (62%). The majority of women were very/somewhat comfortable with provider-initiated (97.4%) versus self-initiated (68.7%) approaches. Women's ability to be honest with their provider about emotional health was most strongly associated with comfort with each method of screening. Conclusions The majority of pregnant women viewed prenatal mental health screening favorably and were comfortable with a variety of screening methods. These findings provide evidence of high acceptability of screening—a key criterion for implementation of universal screening—and suggest that providers can select from a variety of screening methods best suited for their clinical setting.

IntroductionBreast feeding is associated with many health benefits for mothers and infants. But despite extensive public health efforts to promote breast feeding, many mothers do not achieve their own breastfeeding goals; and, inequities in breastfeeding rates persist between high and low-income mother–infant dyads. Developing targeted programme to support breastfeeding dyads and reduce inequities between mothers of different socioeconomic status are a priority for public health practitioners and health policy decision-makers; however, many jurisdictions lack the timely and comprehensive population-level data on infant-feeding practices required to monitor trends in breastfeeding initiation and duration. This protocol describes the establishment of a population-based infant-feeding database in the Canadian province of Manitoba, providing opportunities to develop and evaluate breastfeeding support programme.Methods and analysisRoutinely collected administrative health data on mothers’ infant-feeding practices will be captured during regular vaccination visits using the Teleform fax tool, which converts handwritten information to an electronic format. The infant-feeding data will be linked to the Manitoba Population Research Data Repository, a comprehensive collection of population-based information spanning health, education and social services domains. The linkage will allow us to answer research questions about infant-feeding practices and to evaluate how effective current initiatives promoting breast feeding are.Ethics and disseminationApprovals have been granted by the Health Research Ethics Board at the University of Manitoba. Our integrative knowledge translation approach will involve disseminating findings through government and community briefings, presenting at academic conferences and publishing in scientific journals.

Objective The late preterm population [34–36 weeks gestational age (GA)] is known to incur increased morbidity in the infancy stage compared to the population born at term (39–41 weeks GA). This study aimed to examine the health of these children during their early childhood years, with specific attention to the role of socioeconomic status. Methods A retrospective cohort study was conducted using data from the Manitoba Centre for Health Policy, including all live-born children born at 34–36 and 39–41 weeks GA in urban Manitoba between 2000 and 2005 (n = 28,100). Multivariable logistic regression was used to examine the association of GA with early childhood morbidity after controlling for maternal, child and family level variables. Results The late preterm population was found to have significantly greater adjusted odds of lower respiratory tract infections in the preschool years (aOR = 1.59 [1.24, 2.04]) and asthma at school age (aOR = 1.33 [1.18, 1.47]) compared to the population born at term. The groups also differed in health care utilization at ages 4 (aOR = 1.19 [1.06,1.34]) and 7 years (aOR = 1.24 [1.09, 1.42]). Additional variables associated with poor outcomes suggest that social deprivation and GA simultaneously have a negative impact on early childhood development. Conclusions for Practice Adjustment for predictors of poor early childhood development, including socioeconomic status, were found to attenuate but not eliminate health differences between children born late preterm and children born at term. Poorer health outcomes that extend into childhood have implications for practice at the population level and suggest a need for further follow-up post discharge.

To assess whether partner disengagement from pregnancy is associated with adverse maternal and infant outcomes.We analyzed data from the 2006-2007 Canadian Maternity Experiences Survey, comprising a cross-sectional representative sample of 6,421 childbearing women. Multiple logistic regression assessed the association between adverse outcomes and three indicators of partner disengagement: (1) partner did not want the pregnancy, (2) partner argued more than usual in the year prior to the baby's birth, and (3) partner was absent at the delivery.Of all respondents, 3.8% had partners who did not want the pregnancy, 16.1% argued more than usual with their partner in the past year, and 7.6% had partners who were absent at the delivery. Women whose partner did not want the pregnancy were more likely to report intimate partner violence (IPV) (adjusted odds ratio [AOR] 3.55; 95% confidence interval [95% CI] 2.36-5.14), elevated depressive symptoms in the extended postpartum period (AOR 2.56, 95% CI 1.70-3.83), and nonroutine child healthcare visits after birth (AOR 1.54, 95% CI 1.13-2.11). Women whose partner argued more in the past year had higher odds of IPV (AOR 4.82, 95% CI 3.69-6.30), elevated depressive symptoms in the extended postpartum period (AOR 3.63; 95% CI 2.84-4.64), and nonroutine child healthcare visits (AOR 1.49, 95% CI 1.26-1.77), after adjustment for potential confounders.Partner disengagement is common and is associated with adverse maternal and infant outcomes. Affected women may benefit from special assistance during pregnancy and after delivery.

Background Preterm births (PTB) and small-for-gestational-age (SGA) births are distinct but related pregnancy outcomes, with differing aetiologies and short and long-term morbidities. Few studies have compared a broad array of predictors among these two outcomes. The purpose of this study was to compare risk factors for PTB and SGA births using a national sample of Canadian women. Methods We analysed data from the Canadian Maternity Experiences Survey (n = 6421). Mothers were ≥15 years of age, gave birth to a singleton infant and were living with their infant at the time of the interview (between 5 and 14 months post-partum). Backward stepwise multivariable logistic regression models were constructed for each outcome. Results Risk profiles for the two outcomes had both differences and similarities. Risk factors specific to PTB were education less than high school, having a previous medical condition, developing a new medical condition or health problem during pregnancy, being a primigravida, or being a multigravida with a previous PTB or a previous miscarriage or abortion. Risk factors unique to SGA were low pre-pregnancy body mass index (

To examine associations between breastfeeding initiation and subsequent diabetes among First Nations (indigenous people in Canada who are not Métis or Inuit) and non-First Nations mothers and their offspring with and without gestational diabetes mellitus (GDM).This retrospective database study included 334,553 deliveries (1987-2011) in Manitoba with up to 24 years of follow-up for diabetes using population-based databases. Information of breastfeeding initiation before hospital discharge was obtained from hospital abstracts recorded by nurses in postpartum wards. Cox proportional hazard models were applied to examine the association between breastfeeding initiation and risk of diabetes in mothers and their offspring.Breastfeeding initiation was recorded in 83% of non-First Nations mothers and 56% of First Nations mothers (P.001). Breastfeeding initiation was associated with a reduced risk of incident (later developed) diabetes in non-First Nations mothers without GDM (hazard ratio [HR] 0.73 [or -27% of risk], 95% confidence interval [CI] 0.68-0.79), non-First Nations mothers with GDM (HR 0.78 or -22% of risk, CI 0.69-0.89), First Nations mothers without GDM (HR 0.89 or -11% of risk, CI 0.81-0.98), and First Nations mothers with GDM (HR 0.82 or -18% of risk, CI 0.73-0.92) with 24 years of follow-up or less. With 24 years of follow-up or less, breastfeeding initiation was associated with a 17% lower risk of youth-onset type 2 diabetes in offspring (HR 0.83, CI 0.69-0.99, P=.038). The association between breastfeeding initiation and subsequent diabetes in mothers and offspring was independent of family income, rural residence, First Nations status, GDM, parity, gestational hypertension, and age of the mother.Breastfeeding initiation is associated with a reduced risk of diabetes among women and their offspring in Manitoba. The results suggest that breastfeeding might be a potentially modifiable factor to reduce the risk of diabetes in both First Nations and non-First Nations women and children.

Introduction: Over the last 3 decades, the proportion of women who have delayed childbearing into their mid 30s and early 40s has been increasing. Because advanced maternal age (AMA) is associated with several adverse maternal, fetal, and neonatal outcomes, these pregnancies are considered to be “high risk.” Research indicates that pregnancy risk perception is an important factor in pregnant women's health care use and decision making during pregnancy. The objectives of this study were to compare risk perception in pregnant women of AMA (aged 35 years or older) with that of younger women and to explore the relationship between perception of pregnancy risk and selected variables. Methods: A sample of 159 nulliparous pregnant women (105 aged 20-29 years and 54 aged 35 years or older) was recruited from a variety of settings in Winnipeg, Manitoba, Canada. Women were asked to complete questionnaires to assess perception of pregnancy risk, risk knowledge, pregnancy-related anxiety, perceived control, health status, and medical risk. Results: Women of AMA had higher education levels, were more likely to work during pregnancy, and had higher medical risk scores than younger women. Women of AMA perceived higher pregnancy risk for both themselves and their fetuses than did younger women. They rated their risks of cesarean birth, dying during pregnancy, preterm birth, and having a newborn with a birth defect or one needing admission to a neonatal intensive care unit higher than those of younger women. There were no significant differences between the 2 age groups in pregnancy-related anxiety, knowledge of risk, perceived control, and health status. Discussion: Women of AMA have a higher perception of pregnancy risk than younger women, regardless of their medical risk. This evidence suggests that incorporating discussions of pregnancy risk into prenatal care visits may assist pregnant women of AMA to make more informed choices, reduce anxiety, and avoid unnecessary interventions.

Objectives Although several studies have examined risk factors associated with abuse during pregnancy or postpartum periods, many used clinic-based or small regional samples, and few were national or population-based, limiting their generalizability and clinical utility. The purpose of this study was to describe the correlates of abuse around the time of pregnancy among a nationally representative sample of women in Canada. Methods Using data from 6421 postpartum women (weighted n = 76,500) who completed the Canadian Maternity Experiences Survey from 10/2006 to 01/2007, we explored the association between demographic, psychosocial, behavioral, medical/obstetric factors and ‘any’ and ‘severe’ abuse. ‘Any abuse’ was defined as an affirmative answer to one or more of 10 items asked about physical or sexual abuse or threats of abuse. ‘Severe abuse’ was defined as experiencing a combination of threats and physical or sexual abuse. Odds ratios and their 95 % confidence intervals were generated from multivariable logistic regression models. Results 10.5 % of women (weighted n = 8400) reported ‘any’ abuse and 4.3 % (weighted n = 3400) reported ‘severe’ abuse in the previous 2 years. Correlates of severe abuse included: age

Background and Purpose: To assess the psychometrics of the French language Quality of Prenatal Care Questionnaire (QPCQ). Methods: Data from 302 women were used in a confirmatory factor analysis and in assessment of construct validity through hypothesis testing and internal consistency reliability using Cronbach's alpha. Results: The 6 factors (subscales) were verified and confirmed. Hypothesis testing further supported construct validity. The overall QPCQ had acceptable internal consistency reliability (Cronbach's alpha = .97) as did 5 subscales (Cronbach's alpha = .70-.92); the Sufficient Time subscale had poorer reliability (Cronbach's alpha = .61). Conclusions: The French language QPCQ is a valid and reliable self-report measure of prenatal care quality. It can be used in research and in quality improvement work to strengthen prenatal care services.Keywords: prenatal care; quality of health care; questionnaires; psychometrics; translation; FrenchPrenatal care is a widely used health service in Canada. The Canadian Maternity Experiences Survey found that all women surveyed had at least one prenatal care visit, with an average number of 13 visits (Public Health Agency of Canada, 2009). Prenatal care encompasses "the detection, treatment, or prevention of adverse maternal, fetal, and infant outcomes as well as interventions to address psychosocial stress, detrimental health behaviors such as substance abuse, and adverse socioeconomic conditions" (Alexander & Kotelchuck, 2001, p. 316). However, the evidence for the efficacy and effectiveness of prenatal care has not been firmly established (Alexander & Kotelchuck, 2001; Moos, 2006). Research traditionally has focused on the association between adequacy of prenatal care, determined by the timing of initiation of care and number of visits, and pregnancy outcomes (Heaman, Newburn-Cook, Green, Elliott, & Helewa, 2008). As suggested by Alexander and Kotelchuck (2001), more attention needs to be given to attributes of the health care system and the prenatal care provider, and how these attributes influence the outcomes of prenatal care.These attributes reflect the structure and process of care elements of Donabedian's (1966, 1988) quality of care model; the health care system determines the structure of care whereas prenatal care providers enact clinical and interpersonal care processes. Several studies have highlighted the potential importance of the quality of prenatal care encounters. The content of prenatal care often is considered a quality indicator and there is evidence that health promotion advice (Wilkinson & McIntyre, 2012), attention to risk factors (Public Health Agency of Canada, 2010), and adherence to prenatal care guidelines (Handler, Rankin, Rosenberg, & Sinha, 2012) can improve outcomes. Also, group prenatal care, which was designed to improve quality of care and perinatal outcomes by attending to recommended prenatal care content (Massey, Rising, & Ickovics, 2006), has been found to contribute to higher levels of prenatal knowledge, readiness for labor and birth, and satisfaction with care when compared to traditional prenatal care (Homer et al., 2012). Whereas quality of prenatal care might be equally or more important than quantity of care (Sword et al., 2012), research to examine relationships between care quality and various outcomes has been hindered by the lack of a comprehensive, theoretically grounded measure of the quality of prenatal care (Heaman et al., 2014).In response to this scientific gap, the 46-item Quality of Prenatal Care Questionnaire (QPCQ) was developed and tested with samples of English-speaking women recruited from five major urban centers across Canada (Heaman et al., 2014). As reported by Heaman et al. (2014), the development of the instrument was guided by Donabedian's (1966, 1988) model of quality care. Instrument development was further informed by the work of Campbell, Roland, and Buetow (2000), who defined key components of Donabedian's structure and process categories (Heaman et al. …

Objective: The objective of this qualitative descriptive study was to explore the perceptions of women living in inner-city Winnipeg, Canada, about barriers, facilitators, and motivators related to their use of prenatal care. Methods: Individual, semi-structured interviews were conducted in person with 26 pregnant or postpartum women living in inner-city neighborhoods with high rates of inadequate prenatal care. Interviews averaged 67 min in length. Recruitment of participants continued until data saturation was achieved. Inductive content analysis was used to identify themes and subthemes under four broad topics of interest (barriers, facilitators, motivators, and suggestions). Sword’s socio-ecological model of health services use provided the theoretical framework for the research. This model conceptualizes service use as a product of two interacting systems: the personal and situational attributes of potential users and the characteristics of health services. Results: Half of the women in our sample were single and half self-identified as Aboriginal. Participants discussed several personal and system-related barriers affecting use of prenatal care, such as problems with transportation and child care, lack of prenatal care providers, and inaccessible services. Facilitating factors included transportation assistance, convenient location of services, positive care provider qualities, and tangible rewards. Women were motivated to attend prenatal care to gain knowledge and skills and to have a healthy baby. Conclusion: Consistent with the theoretical framework, women’s utilization of prenatal care was a product of two interacting systems, with several barriers related to personal and situational factors affecting women’s lives, while other barriers were related to problems with service delivery and the broader healthcare system. Overcoming barriers to prenatal care and capitalizing on factors that motivate women to seek prenatal care despite difficult living circumstances may help improve use of prenatal care by inner-city women.

Objective To explore the factors associated with high rates of perceived prenatal stress among inner-city women. Design Observational cross-sectional study. Setting/Participants We conducted a secondary analysis of data from 603 inner-city women. In our study, 330 participants (54.7%) self-identified as First Nations, Metis, or First Nations/Metis. Methods Prenatal stress was measured with Cohen's Perceived Stress Scale. A social ecological model provided the theoretical framework for the study, and variables representing all levels of the model were selected for study. Data analyses included t tests to compare women with high stress and low/moderate stress, univariable logistic regression analysis to determine the association of selected factors with maternal stress, and multivariable logistic regression analysis to provide adjusted odds ratios and 95% confidence intervals for the factors. Results Of the 603 participants, 17.2% (104) reported high levels of perceived stress, and 82.8% (499) reported low/moderate levels. The high-stress group included a significantly greater proportion of First Nations, Metis, or First Nations/Metis women (76.0%) than the low/moderate–stress group (50.3%). Low rates of self-esteem and social support, residential mobility, abuse before/during pregnancy, and experiencing discrimination were significantly associated with high levels of perceived prenatal stress. Conclusion Our findings demonstrated that factors that influence prenatal stress occur at all levels of the social ecological model. The identified factors are amenable to change, and implications for practice include the need for psychosocial risk assessment, alternative forms of prenatal care, relational care, and advocacy initiatives. A greater understanding of the complex factors associated with high rates of perceived prenatal stress can inform the development of effective interventions for inner-city women.

Objective To compare the maternity experiences of immigrant women (recent, ≤ 5 years in Canada; non-recent > 5 years) with those of Canadian-born women. Methods This study was based on data from the Canadian Maternity Experiences Survey of the Public Health Agency of Canada. A stratified random sample of 6421 women was drawn from a sampling frame based on the 2006 Canadian Census of Population. Weighted proportions were calculated using survey sample weights Multivariable logistic regression was used to estimate odds ratios comparing recent immigrant women with Canadian-born women and non-recent immigrant women with Canadian-born women, adjusting for education, income, parity, and maternal age. Results The sample comprised 7.5% recent immigrants, 16.3% non-recent immigrants, and 76.2% Canadian-born women. Immigrant women reported experiencing less physical abuse and stress, and they were less likely to smoke or consume alcohol during pregnancy, than Canadian women; however, they were more likely to report high levels of postpartum depression symptoms and were less likely to have access to social support, to take folic acid before and during pregnancy, to rate their own and their infant's health as optimal, and to place their infants on their backs for sleeping Recent and non-recent immigrant women also had different experiences, suggesting that duration of residence in Canada plays a role in immigrant women's maternity experiences. Conclusion These findings can assist clinicians and policy-makers to understand the disparities that exist between immigrant and non-immigrant women in order to address the needs of immigrant women more effectively.

Purpose This study aimed to (a) psychometrically assess the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) antenatally and postnatally among adolescents, and (b) examine the relationship between breast-feeding self-efficacy and adolescent demographic variables. The BSES-SF is used internationally but has not been psychometrically tested with an adolescent population. Methods A methodological study was conducted in which 103 pregnant adolescents were recruited from two prenatal clinics at a tertiary care setting in western Canada. The BSES-SF was administered at 34 weeks' gestation and again at 1 and 4 weeks postpartum. Results The Cronbach's alpha coefficient was .84 for the antenatal assessment and .93 for the postnatal assessment. Antenatal BSES-SF scores significantly predicted breast-feeding initiation, whereas antenatal and postnatal scores predicted duration and exclusivity to 4 weeks postpartum. Other reliability and validity results are consistent with previous research with adult samples. Study findings indicate prenatal classes and professional support may be particularly important sources of information to increase adolescent breast-feeding self-efficacy. Conclusions Results provide evidence that the scale may be a valid and reliable measure of breast-feeding self-efficacy among adolescents, predicting breast-feeding initiation, duration, and exclusivity.

Prenatal maternal stress has been linked to multiple adverse outcomes. Researchers have used a variety of methods to assess maternal stress. The purpose of this study was to explore and compare factors associated with stress in pregnancy as measured by perceived stress and stressful life events. We analyzed data from the Canadian Maternity Experiences Survey. A randomly selected sample of 8,542 women who had recently given birth was drawn from the 2006 Canadian Census. Women were eligible if they were at least 15 years of age, had delivered a live, singleton infant, and were living with their infant at the time of the interview (5-14 months postpartum). Prevalence estimates and odds ratios were calculated using sample weights of the survey and their variances were calculated using bootstrapping methods. Bivariate analyses identified statistically significant factors associated with each stress measure. Backward stepwise multivariate logistic regression models were constructed. A total of 6,421 women (78%) participated in the computer assisted telephone interview. Twelve percent of women experienced high levels of perceived stress and 17.1% reported having three or more stressful life events in the year prior to the birth of their baby. In the final model, psychosocial variables were associated with both outcomes, whereas demographic factors were associated only with life event stress. Different factors contributed to perceived stress and life event stress, suggesting that these concepts measure different aspects of stress. These findings can inform routine psychosocial risk assessment in pregnancy.

Background In circumpolar countries such as Canada, northern regions represent a unique geographical entity climatically, socioeconomically and environmentally. There is a lack of comparative data on birth outcomes among Indigenous and non-Indigenous subpopulations within northern regions and compared with southern regions. Methods A cohort study of all births by maternal mother tongue to residents of northern (2616 First Nations (North American Indians), 2388 Inuit and 5006 non-Indigenous) and southern (2563 First Nations, 810 643 non-Indigenous) Quebec, 1991–2000. Results Compared with births to southern non-Indigenous mother tongue women, births to northern women of all three mother tongue groups were at substantially elevated risks of infant death (adjusted OR (aOR) 1.7–2.9), especially postneonatal death (aOR 2.2–4.4) after controlling for maternal education, age, marital status and parity. The risk elevation in perinatal death was greater for southern First Nations (aOR 1.6) than for northern First Nations (aOR 1.2). Infant macrosomia was highly prevalent among First Nations in Quebec, especially in the north (31% vs 24% in the south). Within northern regions, Inuit births were at highest risk of preterm delivery (aOR 1.4) and infant death (aOR 1.6). Conclusion All northern infants (First Nations, Inuit or non-Indigenous) were at substantially elevated risk of infant death in Quebec, despite a universal health insurance system. Southern First Nations newborns have not benefited from the more advanced perinatal care facilities in southern regions. Environmental influences may partly account for the very high prevalence of macrosomia among First Nations in northern Quebec.

Objective: Little is known about the possible impacts of neighborhood socioeconomic status on birth outcomes and infant mortality among Aboriginal populations. We assessed birth outcomes and infant mortality by neighborhood so- cioeconomic status among First Nations and non-First Nations in Manitoba. Study Design: We conducted a retrospective birth cohort study of all live births (26,176 First Nations, 129,623 non-First Nations) to Manitoba residents, 1991-2000. Maternal residential postal codes were used to assign four measures of neigh- borhood socioeconomic status (concerning income, education, unemployment, and lone parenthood) obtained from 1996 census data. Results: First Nations women were much more likely to live in neighborhoods of low socioeconomic status. First Nations infants were much more likely to die during their first year of life (risk ratio (RR) =1.9) especially during the postneonatal period (RR=3.6). For both First Nations and non-First Nations, living in neighborhoods of low socioeconomic status was associated with an increased risk of infant death, especially postneonatal death. For non-First Nations, higher rates of pre- term and small-for-gestational-age birth were consistently observed in low socioeconomic status neighborhoods, but for First Nations the associations were less consistent across the four measures of socioeconomic status. Adjusting for neigh- borhood socioeconomic status, the disparities in infant and postneonatal mortality between First Nations and non-First Nations were attenuated. Conclusion: Low neighborhood socioeconomic status was associated with an elevated risk of infant death even among First Nations, and may partly account for their higher rates of infant mortality compared to non-First Nations in Manitoba.

Objective: There is limited and inconsistent evidence concerning rural versus urban differences in birth and in- fant outcomes for Indigenous peoples. We assessed birth and infant outcomes among Inuit, First Nations and French mother tongue groups by rural versus urban residence in Quebec, Canada. Study Deign: A retrospective birth cohort study of 5,184 First Nations, 2,527 Inuit and 652,940 French mother tongue (the majority reference) births in Quebec, 1991-2000. Results: In general, rural living was associated with slightly less favorable birth outcomes for French mother tongue women, but somewhat better outcomes for Indigenous women. For both Inuit and First Nations, rural births were half as likely to be small-for-gestational-age compared to urban births. Among First Nations, the difference in infant mortality rates comparing urban to rural areas was not statistically significant. Compared to infants of French mother tongue women, Inuit and First Nations infants were much less likely to be small-for-gestational-age in rural areas, while such an "advantage" diminished for First Nations and reversed for Inuit in urban areas. The disparities in infant mortality among First Nations versus French mother tongue births were greater in urban than in rural areas. These patterns of results re- mained after adjusting for maternal characteristics. Conclusion: Living in urban areas was not associated with better birth and infant outcomes for Inuit and First Nations in Quebec despite universal health insurance coverage, strongly indicating a need for improved socioeconomic conditions, perinatal and infant care for Indigenous people living in urban areas.

Objective: to determine the relationship of north-south place of residence to adverse birth outcomes among First Nations and non-First Nations in Manitoba, Canada, a setting with universal health insurance. Study Design: Live birth records (n=151,472) for the province of Manitoba, Canada 1991-2000 were analyzed, including 25,743 First Nations and 125,729 non-First Nations infants. North-south and rural-urban residence was determined for each birth through geocoding. Results: Comparing First Nations to non-First Nations, crude rates in North (and South) were: 7.0% versus 8.4% (9.3% versus 7.5%) for preterm birth; 6.1% versus 8.4% (8.7% versus 10.0%) for small-for-gestational-age birth, 4.2% versus 6.5% (6.2% versus 5.7%) for low birth weight, and 20.6% versus 13.7% (17.0% versus 11.0%) for large-for-gestational- age birth; and mortality per 1000 - neonatal 3.2 versus 6.2 (3.8 versus 3.3), post-neonatal 6.4 versus 6.4 (5.8 versus 1.5), and infant 9.5 versus 12.6 (9.6 versus 4.8). Adjusting for observed maternal and infant characteristics and rural versus ur- ban residence, the North was high risk for large-for-gestational-age birth for both First Nations and non-First Nations. First Nations' risk of preterm, small-for-gestational-age and low birth weight was lowest in the North, but for non-First Nations, the North was lower only for small-for-gestational-age. First Nations mortality indicators were similar North to South, but for non-First Nations, the North was high risk. Conclusion: North-South place of residence does matter for adverse birth outcomes, but the effects may differ by ethnicity and could require different intervention strategies.

Objective: We assessed individual- and community-level disparities and trends in birth outcomes and infant mortality among First Nations (North American Indians) and Inuit versus other populations in Quebec, Canada. Methods: A retrospective birth cohort study of all births to Quebec residents, 1991-2000. At the individual level, we ex- amined outcomes comparing births to First Nations and Inuit versus other mother tongue women. At the community level, we compared outcomes among First Nations and Inuit communities versus other communities. Results: First Nations and Inuit births were much less likely to be small-for-gestational-age but much more likely to be large-for-gestational-age compared to other births at the individual or community level, especially for First Nations. At both levels, Inuit births were 1.5 times as likely to be preterm. At the individual level, total fetal and infant mortality rates were 2 times as high for First Nations, and 3 times as high for Inuit. Infant mortality rates were 2 times as high for First Nations, and 4 times as high for Inuit. There were no reductions in these disparities between 1991-1995 and 1996-2000. Modestly smaller disparities in total fetal and infant mortality were observed for First Nations at the community level (risk ratio=1.6), but for Inuit there were similar disparities at both levels. These disparities remained substantial after adjusting for maternal characteristics. Conclusion: There were large and persistent disparities in fetal and infant mortality among First Nations and Inuit versus other populations in Quebec based on individual- or community-level assessments, indicating a need to improve socio- economic conditions as well as perinatal and infant care for Aboriginal peoples.

Objective: Little is known about community remoteness in relation to birth outcomes among Indigenous popu- lations. We assessed whether community remoteness matters for perinatal outcomes and infant mortality in Quebec First Nations communities. Study Design: A retrospective cohort study of all births (n=11,033) to residents of First Nations communities in Quebec 1991-2000, using linked vital statistics data. First Nations communities were grouped by community remoteness into four zones from the least to most remote. Results: Preterm birth rates declined progressively from the least remote (8.0%) to the most remote (5.7%) zones (p=0.002). In contrast, total fetal and infant mortality rose progressively from the least remote (10.4 per 1000) to the most remote (22.7 per 1000) zones (p

Birth outcomes are persistently worse among Aboriginal as compared to non-Aboriginal populations even in developed countries.1–10 The underlying causes remain incompletely understood. Several studies indicate that the place of residence may affect the disparities in birth outcomes and infant mortality when comparing Aboriginal versus non-Aboriginal populations. Among North American Indians (the Canadian equivalent term “First Nations”) and Alaskan Natives compared to whites in the United States, greater disparities in infant mortality have been reported in some urban areas than in rural areas.3,4 In British Columbia, the disparity in infant mortality when comparing First Nations to non-First Nations declined less substantially and less consistently in urban versus rural areas.2 A recent Australian study found that the disparity in infant mortality when comparing Aboriginal versus non-Aboriginal populations was larger in remote rural areas.6 However, it is unknown whether the degree of rural isolation per se may affect birth outcomes and infant mortality differentially among Aboriginal versus non-Aboriginal populations. The question may be of particular importance due to the increasing migration of Aboriginal people to less isolated areas over recent decades. Although many Aboriginal people have moved from rural to urban or near-urban areas, substantially higher proportions of the Aboriginal population remain living in rural and more isolated areas compared to the non-Aboriginal population. According to the 2001 census, 57% of the First Nations population of Canada lived in rural areas, compared to 20% of the non-Aboriginal population. We hypothesized that the degree of rural isolation may affect birth outcomes and infant mortality differentially among Aboriginal and non-Aboriginal populations, presumably because of the Aboriginal versus non-Aboriginal differences in access to and effective use of the better care facilities in urban centers, and the differences in socioeconomic conditions and other risk factors. The primary aim of this study was to evaluate whether the degree of rural isolation may differentially affect birth outcomes and infant mortality among First Nations and non-First Nations in Manitoba, Canada, a setting with universal health insurance.

Pregnant women's perception of risk may influence their health behaviors during pregnancy; however, no validated instrument exists to measure those perceptions. The purpose of this study was to refine a new instrument, the Perception of Pregnancy Risk Questionnaire (PPRQ), and conduct psychometric assessment of the final 9-item version. Reliability and validity were assessed using a sample of 199 women in the third trimester of pregnancy. Exploratory factor analysis resulted in a two-factor solution. Evidence of construct validity was demonstrated using the known-groups technique and through convergent validity. Ratings of pregnancy risk correlated with state anxiety level, providing evidence of concurrent validity. The PPRQ had high internal consistency reliability and excellent test–retest reliability. © 2009 Wiley Periodicals, Inc. Res Nurs Health 32:493–503, 2009

Background: There is a lack of data on the safety of midwife-led maternity care in remote or Indigenous communities. In a de facto natural "experiment", we assessed birth outcomes by primary birthing attendant in two sets of remote Inuit communities. Methods: A geocoding-based retrospective birth cohort study in 14 Inuit communities of Nunavik, Canada, 1989-2000: primary birth attendants were Inuit midwives in the Hudson Bay (1,529 Inuit births) versus Western physicians in Ungava Bay communities (1,197 Inuit births). The primary outcome was perinatal death. Secondary outcomes included stillbirth, neonatal death, postneonatal death, preterm, small-for-gestational-age and low birth weight birth. Multi-level logistic regression was used to obtain the adjusted odds ratios (aOR) controlling for maternal age, marital status, parity, education, infant sex and plurality, community size and community-level random effects. Results: The aOR (95% confidence interval) for perinatal death comparing the Hudson Bay versus Ungava Bay communities were 1.29 (0.63, 2.64) for all Inuit births, and 1.13 (0.48, 2.47) for Inuit births at >=28 weeks of gestation. There were no statistically significant differences in the crude or adjusted risks of any of the outcomes examined. Conclusion: Risks of perinatal death were somewhat but not significantly higher in the Hudson Bay communities with midwife-led maternity care as compared to the Ungava Bay communities with physician-led maternity care. Our findings are inconclusive, although the results excluding extremely preterm births are more reassuring concerning the safety of midwife-led maternity care in remote Indigenous communities.

Resume Objectif Offrir des conseils aux cliniciens qui participent au processus de choix eclaire en ce qui a trait au don d'embryons humains a des fins de recherche. Recommandations 1.Comme le stipulent les lignes directrices des Instituts de recherche en sante du Canada et la Loi sur la procreation assistee, le consentement explicite tant des donneurs de gametes que des donneurs d'embryons est requis avant que des embryons ne puissent etre utilises a des fins de recherche. Les donneurs de gametes et les fournisseurs d'embryons peuvent ne pas etre les memes personnes lorsque la creation d'embryons fait appel a des dons de gametes. 2.Le processus de consentement doit indiquer ce qui suit aux donneurs potentiels: les types possibles (et, dans le cas du consentement final, le type particulier) de projet de recherche dans le cadre desquels les embryons seront utilises; les risques associes au don d'embryons a la recherche, tel que le risque de ne plus avoir par la suite acces a ces embryons a des fins genesiques; le fait que la femme / le couple ne tireront pas personnellement profit du don d'embryons a la recherche; les gains commerciaux que pourront potentiellement en tirer des tierces parties; la possibilite que l'on communique avec eux a l'avenir au sujet de la disposition des embryons; le fait que la confidentialite ne peut faire l'objet d'une protection absolue. 3.La designation selon laquelle les embryons cryoconserves n'etant plus requis a des fins genesiques doivent etre donnes a la recherche, donnes a un autre couple ou elimines doit faire l'objet d'une discussion avant la recuperation des gametes et etre etablie au moment de la cryoconservation, les personnes concernees comprenant bien que, a l'avenir, un consentement final sera requis. La decision finale quant au don d'embryons cryoconserves ne devrait pas etre prise avant que la femme / le couple n'aient decide qu'ils n'ont plus besoin des embryons en question a des fins genesiques. La decision de mettre fin a la cryoconservation des embryons et la decision quant a leur disposition doivent etre prises separement. La femme / le couple devront etre consultes a nouveau en ce qui a trait a la disposition finale de leurs embryons. 4.Compte tenu du manque de donnees scientifiques quant a la previsibilite de la caracterisation microscopique des embryons et de leur potentiel d'engendrer une grossesse, il est recommande d'offrir a toutes les femmes / tous les couples l'occasion de cryoconserver tous les embryons n'ayant pas ete transferes au cours du cycle de traitement et de les aviser que le fait de ne pas proceder a la cryoconservation de ces embryons peut accroitre leur risque de devoir subir un cycle supplementaire de FIV afin d'atteindre leurs objectifs genesiques. 5.Les participants a la recherche doivent etre avises du fait qu'ils peuvent retirer leur consentement en tout temps avant la decongelation des embryons a des fins de recherche ou, dans le cas de la recherche sur les cellules souches, la creation d'une lignee de cellules souches. 6.Les donneurs potentiels doivent etre avises que leurs soins medicaux ne seront aucunement affectes par leur decision quant au don d'embryons.

A prospective correlational study was conducted to examine the influence of adolescent mothers' breastfeeding attitudes and confidence on breastfeeding initiation and duration. A convenience sample of 100 pregnant adolescents who were contemplating breastfeeding completed the Breastfeeding Self-Efficacy Scale—Short Form (BSES-SF) and the Breastfeeding Attitude Questionnaire (BAQ). The BSES-SF was readministered during the first week postpartum to those adolescents who initiated breastfeeding (n = 84). Adolescents who were breastfeeding at the initial contact received a follow-up contact at 4 weeks postpartum. Comparisons were made between those adolescent mothers who initiated breastfeeding (n = 84) and those who did not (n = 16). Significantly more mothers with higher prenatal attitude scores initiated breastfeeding. Mothers with higher prenatal breastfeeding attitude scores and higher prenatal and postnatal confidence scores were more likely to continue breastfeeding to 4 weeks postpartum. Health professionals are encouraged to develop strategies to enhance breastfeeding attitudes and confidence among adolescent mothers. J Hum Lact. 24(3):268-277.

Objective To explore the practices of Canadian obstetricians, family physicians, and midwives in recommending bed rest or activity restriction for women at risk for preterm birth (PTB) and to assess the decisional conflict experienced by care providers when they recommend these therapies. Methods A self-administered mail survey of prenatal care providers was carried out using Dillman's Tailored Design Method . Analysis included descriptive statistics and analysis of variance. Results The survey was distributed to 1441 potential participants; of these, 1172 were eligible participants, and 516 (44.2%) completed the survey. For women at risk of PTB, 60 of 170 obstetricians (35%), 88 of 206 family practitioners (42.7%), and 30 of 140 midwives (21.4%) recommended bed rest in hospital; 110 of 170 obstetricians (64.7%), 144 of 206 family practitioners (69.9%), and 73 of 140 midwives (52.1%) recommended bed rest at home. These recommendations occurred despite the response from about two thirds of each professional group that the effectiveness of bed rest was in the fair-to-poor range in helping to prevent PTB. The mean score on the Provider Decision Process Assessment Instrument, measuring decisional conflict for all care provider groups, was 30 (SD 7.4) (possible score range 12–60). There were no significant differences in decisional conflict scores among provider groups (F [2,347] = 2.24; P=0.11). Conclusion Care providers have been discouraged from routinely recommending bed rest for women at risk of PTB because of potential adverse side effects. This study demonstrates that most Canadian prenatal care providers have not been persuaded to incorporate these recommendations into practice. Except for women with multiple gestation, there is inconsistent practice in recommending bed rest and activity restriction. Additionally, Canadian prenatal care providers have some decisional conflict about using this therapy. These results provide some of the first Canadian perspectives on the practice of prescribing therapeutic bed rest for PTB.

Objective The Maternity Experiences Survey (MES) is an initiative of the Canadian Perinatal Surveillance System. Its primary objective is to provide representative, pan-Canadian data on women’s experiences during pregnancy, birth, and the early postpartum period. Methods The development of the survey involved input from a multidisciplinary study group, an extensive consultation process and two pilot studies. The MES population consisted of birth mothers 15 years of age and over who had a singleton live birth in Canada during a three-month period preceding the 2006 Canadian Census of Population and who lived with their infants at the time of data collection. Experiences of teenage, immigrant, First Nations, Inuit, and Metis mothers were of particular interest. The sample was drawn from the 2006 Canadian Census. A 45-minute interview was conducted at five to 14 months post partum, primarily by telephone by female professional Statistics Canada interviewers. Results A response rate of 78% was achieved, corresponding to 6421 women who were weighted to represent an estimated 76 508 women. The cooperation rate was 92% and the refusal rate was 1.0%. Item non-response was low, and few data errors were identified. The final MES sample was judged to be representative of the corresponding Census population for all characteristics investigated. Conclusion The MES marks an important milestone in the availability of information on maternity experiences in Canada. For the first time, it is possible to provide high quality data at national, provincial, and territorial levels on a wide spectrum of maternity experiences as reported by women.

Background: The rate of elective primary cesarean delivery continues to rise, owing in part to the widespread perception that the procedure is of little or no risk to healthy women. Methods: Using the Canadian Institute for Health Information9s Discharge Abstract Database, we carried out a retrospective population-based cohort study of all women in Canada (excluding Quebec and Manitoba) who delivered from April 1991 through March 2005. Healthy women who underwent a primary cesarean delivery for breech presentation constituted a surrogate “planned cesarean group” considered to have undergone low-risk elective cesarean delivery, for comparison with an otherwise similar group of women who had planned to deliver vaginally. Results: The planned cesarean group comprised 46 766 women v. 2 292 420 in the planned vaginal delivery group; overall rates of severe morbidity for the entire 14-year period were 27.3 and 9.0, respectively, per 1000 deliveries. The planned cesarean group had increased postpartum risks of cardiac arrest (adjusted odds ratio [OR] 5.1, 95% confidence interval [CI] 4.1–6.3), wound hematoma (OR 5.1, 95% CI 4.6–5.5), hysterectomy (OR 3.2, 95% CI 2.2–4.8), major puerperal infection (OR 3.0, 95% CI 2.7–3.4), anesthetic complications (OR 2.3, 95% CI 2.0–2.6), venous thromboembolism (OR 2.2, 95% CI 1.5–3.2) and hemorrhage requiring hysterectomy (OR 2.1, 95% CI 1.2–3.8), and stayed in hospital longer (adjusted mean difference 1.47 d, 95% CI 1.46–1.49 d) than those in the planned vaginal delivery group, but a lower risk of hemorrhage requiring blood transfusion (OR 0.4, 95% CI 0.2–0.8). Absolute risk increases in severe maternal morbidity rates were low (e.g., for postpartum cardiac arrest, the increase with planned cesarean delivery was 1.6 per 1000 deliveries, 95% CI 1.2–2.1). The difference in the rate of in-hospital maternal death between the 2 groups was nonsignificant (p = 0.87). Interpretation: Although the absolute difference is small, the risks of severe maternal morbidity associated with planned cesarean delivery are higher than those associated with planned vaginal delivery. These risks should be considered by women contemplating an elective cesarean delivery and by their physicians.

Background Few studies have explored predictors of early childhood anxiety. Objective To determine the prenatal, postnatal, and early life predictors of childhood anxiety by age 5. Methods Population-based, provincial administrative data (N = 19,316) from Manitoba, Canada were used to determine the association between demographic, obstetrical, psychosocial, medical, behavioral, and infant factors on childhood anxiety. Results Risk factors for childhood anxiety by age 5 included maternal psychological distress from birth to 12 months and 13 months to 5 years post-delivery and an infant 5-minute Apgar score of ≤7. Factors associated with decreased risk included maternal age < 20 years, multiparity, and preterm birth. Conclusion Identifying predictors of childhood anxiety is a key step to early detection and prevention. Maternal psychological distress is an early, modifiable risk factor. Future research should aim to disentangle early life influences on childhood anxiety occurring in the prenatal, postnatal, and early childhood periods.