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Background: Hypertensive disorders of pregnancy (HDP) are a leading cause of severe maternal morbidity (SMM). We sought to explore trends in HDP and related morbidity outcomes in Canada. Methods: In this retrospective population-based study, we used hospital discharge data from Canada, excluding Quebec, to identify females who had an HDP diagnosis during a birth admission between 2012 and 2021. We analyzed temporal and geographical trends in HDP, as well as temporal trends in adverse outcomes associated with HDP. Results: Among 2 804 473 hospital admissions for birth between 2012 and 2021, the rate of any HDP increased from 6.1% to 8.5%, including pre-existing hypertension (0.6% to 0.9%), gestational hypertension (3.9% to 5.1%), and preeclampsia (1.6% to 2.6%). For 2017-2021 combined, relative to Ontario (6.9%), HDP were significantly more prevalent in nearly all other Canadian regions. For example, in Newfoundland and Labrador, the rate was 10.7% (unadjusted rate ratio 1.56, 95% confidence interval 1.49-1.63). Among females with any HDP, rates of cesarean delivery rose from 42.0% in 2012 to 44.3% in 2021, as did acute renal failure (0.4% to 0.6%), while rates of early preterm delivery, intrauterine fetal death, maternal hospital length of stay ([greater than or equal to] 7 d), admission to the maternal intensive care unit, severe hemorrhage, and SMM trended downward. Interpretation: The rate of HDP has risen across Canada, with a concomitant decline in some HDP-associated morbidities. Ongoing surveillance of HDP is needed to assess the factors associated with temporal trends, including the effectiveness of evolving HDP prevention and management efforts., Hypertensive disorders of pregnancy (HDP) include pre-existing (chronic) hypertension, gestational hypertension, and preeclampsia or eclampsia. Globally, hypertensive disorders affect 5%-10% of pregnancies and are responsible for more than 50 000 [...]

Background: Oxycodone is increasingly prescribed for postpartum analgesia in lieu of codeine owing to concerns regarding the neonatal safety of codeine during lactation. We examined whether initiation of oxycodone after delivery was associated with an increased risk of persistent opioid use relative to initiation of codeine. Methods: We conducted a population-based cohort study of people who filled a prescription for either codeine or oxycodone within 7 days of discharge from hospital after delivery between Sept. 1, 2012, and June 30, 2020. The primary outcome was persistent opioid use, defined as 1 or more additional prescriptions for an opioid within 90 days of the first postpartum prescription and 1 or more additional prescriptions in the 91 to 365 days thereafter. We used inverse probability of treatment weighting to assess the risk of persistent postpartum opioid use, comparing people who initiated oxycodone with those who initiated codeine. Results: Over the 8-year study period, we identified 70 607 people who filled an opioid prescription within 7 days of discharge from hospital: 21308 (30.2%) received codeine and 49299 (69.8%) oxycodone. Compared with people who filled a prescription for codeine, receipt of oxycodone was not associated with persistent opioid use (relative risk [RR] 1.04, 95% confidence interval [CI] 0.91-1.20). We found an association between a prescription for oxycodone and persistent use after vaginal delivery (RR 1.63, 95% CI 1.31-2.03), but not after cesarean delivery (RR 0.85, 95% CI 0.73-1.00). Interpretation: Initiation of oxycodone (v. codeine) was not associated with an increased risk of persistent opioid use, except after vaginal delivery., Opioids are commonly prescribed to treat pain after childbirth, but the amount prescribed often far exceeds what is taken. (1,2) In Ontario, about 40% of people who give birth fill [...]

Background: Living in low-income neighbourhoods and being an immigrant are each independently associated with adverse neonatal outcomes, but it is unknown if disparities exist in the neonatal period for children of immigrant and nonimmigrant females living in low-income areas. We sought to compare the risk of severe neonatal morbidity and mortality (SNMM) between newborns of immigrant and nonimmigrant mothers who resided in low-income neighbourhoods. Methods: This population-based cohort study used administrative data for females residing in low-income urban neighbourhoods in Ontario, who had an in-hospital, singleton live birth at 20-42 weeks' gestation, from 2002 to 2019. We defined immigrant status as nonrefugee immigrant or nonimmigrant, further detailed by country of birth and duration of residence in Ontario. The primary outcome was a SNMM composite (with 16 diagnoses, including neonatal death and 7 neonatal procedures as indicators), arising within 0-27 days after birth. We estimated relative risks (RRs) and 95% confidence intervals (CIs) using modified Poisson regression with generalized estimating equations. Results: Our cohort included 148 050 and 266 191 live births among immigrant and nonimmigrant mothers, respectively. Compared with newborns of nonimmigrant females, SNMM was less frequent among newborns of immigrant females (49.7 v. 65.6 per 1000 live births), with an adjusted RR of 0.76 (95% CI 0.74 to 0.79). The most frequent SNMM indicator was receipt of ventilatory support. Relative to neonates of nonimmigrant females, the risk of SNMM was highest among those of immigrants from Jamaica (adjusted RR 1.14, 95% CI 1.05 to 1.23) and Ghana (adjusted RR 1.20, 95% CI 1.05 to 1.38), and lowest among those of immigrants from China (adjusted RR 0.44, 95% CI 0.40 to 0.48). Among immigrants, the risk of SNMM declined with shorter duration of residence before the index birth. Interpretation: Within low-income urban areas, newborns of immigrant females had an overall lower risk of SNMM than those of nonimmigrant females, with considerable variation by maternal birthplace and duration of residence. Initiatives should focus on improving preconception health and perinatal care within subgroups of females residing in low-income neighbourhoods., Neonatal morbidity and mortality are important public health indicators used to monitor and evaluate neonatal health and quality of perinatal care. (1,2) The neonatal period, ranging from birth to 27 [...]

Background: Canada has 2 main streams of resettlement: government-assisted refugees and privately sponsored refugees, whereby citizens can privately sponsor refugees and provide resettlement services, including health care navigation. Our objective was to compare receipt of adequate prenatal care among privately sponsored and government-assisted refugees. Methods: This population-based study used linked health administrative and demographic databases. We included all resettled refugees classified as female who landed in Ontario, Canada, between April 2002 and May 2017, and who had a live birth or stillbirth conceived at least 365 days after their landing date. Our primary outcome--adequacy of prenatal care--was a composite that comprised receipt of a first-trimester prenatal visit, the number of prenatal care visits recommended by the Society of Obstetricians and Gynaecologists of Canada and a prenatal fetal anatomy ultrasound. We accounted for potential confounding with inverse probability of treatment weighting, using a propensity score. Results: We included 2775 government-assisted and 2374 privately sponsored refugees. Compared with privately sponsored refugees (62.3% v. 69.3%), government-assisted refugees received adequate prenatal care less often, with a weighted relative risk of 0.93 (95% confidence interval 0.88-0.95). Interpretation: Among refugees resettled to Canada, a government-assisted resettlement model was associated with receiving less adequate prenatal care than a private sponsorship model. Government-assisted refugees may benefit from additional support in navigating health care beyond the first year after arrival., There are currently about 32.5 million refugees in the world, according to the United Nations High Commissioner for Refugees, (1) and the gap between refugees and available resettlement places is [...]

Background: Schizophrenia is associated with increased risk of experiencing interpersonal violence. Little is known about risk specifically around the time of pregnancy. Methods: This population-based cohort study included all individuals (aged 15-49 yr) listed as female on their health cards who had a singleton birth in Ontario, Canada, between 2004 and 2018. We compared those with and without schizophrenia on their risk of an emergency department (ED) visit for interpersonal violence in pregnancy or within 1 year postpartum. We adjusted relative risks (RRs) for demographics, prepregnancy history of substance use disorder and history of interpersonal violence. In a subcohort analysis, we used linked clinical registry data to evaluate interpersonal violence screening and self-reported interpersonal violence during pregnancy. Results: We included 1 802 645 pregnant people, 4470 of whom had a diagnosis of schizophrenia. Overall, 137 (3.1%) of those with schizophrenia had a perinatal ED visit for interpersonal violence, compared with 7598 (0.4%) of those without schizophrenia, for an RR of 6.88 (95% confidence interval [CI] 5.66-8.37) and an adjusted RR of 3.44 (95% CI 2.86-4.15). Results were similar when calculated separately for the pregnancy (adjusted RR 3.47, 95% CI 2.68-4.51) period and the first year postpartum (adjusted RR 3.45, 95% CI 2.75-4.33). Pregnant people with schizophrenia were equally likely to be screened for interpersonal violence (74.3% v. 73.8%; adjusted RR 0.99, 95% CI 0.95-1.04), but more likely to self-report it (10.2% v. 2.4%; adjusted RR 3.38, 95% CI 2.61-4.38), compared with those without schizophrenia. Among patients who did not self-report interpersonal violence, schizophrenia was associated with an increased risk for a perinatal ED visit for interpersonal violence (4.0% v. 0.4%; adjusted RR 6.28, 95% CI 3.94-10.00). Interpretation: Pregnancy and postpartum are periods of higher risk for interpersonal violence among people with schizophrenia compared with those without schizophrenia. Pregnancy is a key period for implementing violence prevention strategies in this population., Interpersonal violence is defined as the intentional use of force or power against others, including physical, sexual and psychological abuse perpetrated by strangers, acquaintances, family members or intimate partners. (1-5) [...]

Dans le present numero du JAMC, le Dr Jain et son equipe preconisent le depistage multifactoriel du risque de preeclampsie precoce, suivi de la prescription d'acide acetylsalicylique (AAS) en cas [...]

In this issue of CMAJ, Jain and colleagues argue for multifactorial screening for people at risk of early-onset preeclampsia, and acetylsalicylic acid (ASA) initiation for those who screen positive. (1) [...]

Background: People whose singleton pregnancy is affected by hypertensive disorders of pregnancy (HDP) are at risk of future cardiovascular disease. It is unclear, however, whether this association can be extrapolated to twin pregnancies. We aimed to compare the association between HDP and future cardiovascular disease after twin and singleton pregnancies. Methods: We conducted a population-based retrospective cohort study that included nulliparous people in Ontario, Canada, 1992-2017. We compared the future risk of cardiovascular disease among pregnant people from the following 4 groups: those who delivered a singleton without HDP (referent) and with HDP, and those who delivered twins either with or without HDP. Results: The populations of the 4 groups were as follows: 1431651 pregnant people in the singleton birth without HDP group; 98 631 singleton birth with HDP; 21046 twin birth without HDP; and 4283 twin birth with HDP. The median duration of follow-up was 13 (interquartile range 7-20) years. The incidence rate of cardiovascular disease was lowest among those with a singleton or twin birth without HDP (0.72 and 0.74 per 1000 person-years, respectively). Compared with people with a singleton birth without HDP, the risk of cardiovascular disease was highest among those with a singleton birth and HDP (1.47 per 1000 person-years; adjusted hazard ratio [HR] 1.81 [95% confidence interval (CI) 1.72-1.90]), followed by people with a twin pregnancy and HDP (1.07 per 1000 person-years; adjusted HR 1.36 [95% CI 1.04-1.77]). The risk of the primary outcome after a twin pregnancy with HDP was lower than that after a singleton pregnancy with HDP (adjusted HR 0.74 [95% CI 0.57-0.97]), when compared directly. Interpretation: In a twin pregnancy, HDP are weaker risk factors for postpartum cardiovascular disease than in a singleton pregnancy., Cardiovascular disease has been shown to be the leading cause of death among women. (1-3) Classic risk factors for cardiovascular disease include obesity, diabetes mellitus, hypertension and family history of [...]