The All Our Babies pregnancy cohort: design, methods, and participant characteristics

Maternal adverse childhood experiences are associated with binge drinking during pregnancy in a dose-dependent pattern: Findings from the All Our Families cohort

BACKGROUND

Binge drinking (BD) is a serious risk factor for fetal alcohol spectrum disorders (FASD) and associated with more severe forms of the disorder. Thus, special attention to specific risk factors for BD adjacent to and during pregnancy is warranted.

OBJECTIVES

(1) To examine the role that maternal adverse childhood experiences (ACEs) may play in BD in the 12 months before pregnancy and during pregnancy in a sample of women with moderate to high socioeconomic status; and (2) to examine the sociodemographic correlates of BD before and during pregnancy within this sample.

PARTICIPANTS AND SETTING

This secondary analysis (N = 1663) was derived from the All Our Families prospective cohort study collected in Alberta, Canada between 2008-2011.

METHODS

Data were collected using three mailed surveys completed by women during and after pregnancy. An established scale examined maternal ACEs before 18 years. Adjusted logistic regression models tested associations between ACE score and BD before and during pregnancy.

RESULTS

Approximately 5 in 10 (48.3 %) and 1 in 10 (10.0 %) women reported ≥1 BD episode before and during pregnancy; respectively. In adjusted models, a woman's ACE score was associated with BD pre-pregnancy in a weak, nonmonotonic fashion; and during pregnancy in a moderate, dose-response fashion. Overall, ACEs resulted in two to three-fold increase in the odds of BD during pregnancy.

CONCLUSIONS

Maternal ACEs were common in this middle to upper-middle income, well-educated sample and impacted the next generation through BD in pregnancy. These findings combine with others to speak to the public health significance of maternal ACEs on alcohol-related behaviour among expectant mothers across the socioeconomic spectrum, and the need for targeted evidence-based interventions for this population.

Perinatal depression: The role of maternal adverse childhood experiences and social support

BACKGROUND

A strong association between the number of adverse childhood experiences (ACEs) and the risk of maternal depression has been demonstrated; however, this association has not been examined with regards to changes in depression across the perinatal period. The objectives of this longitudinal study were to: (1) determine whether ACEs predict depressive symptomology in pregnancy and the postpartum period; (2) test the relative contribution of ACEs, with other established risks of depression, including social support, and (3) examine whether the association between ACEs and depression across the perinatal period vary as a function of social support.

METHODS

Data from 1994 women were collected from a prospective pregnancy cohort. Women completed questionnaires related to ACEs prior to the age of 18. In pregnancy and at 4 months postpartum, social support was measured using the Medical Outcomes Study Social Support Survey and clinical cut-off scores for depression were assessed using the Edinburgh Postnatal Depression Scale.

RESULTS

Logistic regression demonstrated that after accounting for sociodemographic factors and social support, ACEs predicted depressive symptoms in pregnancy (AOR = =1.26, CI = =1.12-1.43), the postpartum period (AOR = =1.34, CI = =1.17-1.52), and across the perinatal period (AOR = =1.31, CI = =1.12-1.54). Social support did not moderate the association between maternal ACEs and depression for any time point.

LIMITATIONS

retrospective and self-report nature of the data.

CONCLUSION

ACEs and low social support are both risk factors for depression, however low social support predicted the highest odds of depression, indicating the importance of asking about social support in pregnant and postpartum women.

Neighbourhood socioeconomic status modifies the association between anxiety and depression during pregnancy and preterm birth: a Community-based Canadian cohort study

OBJECTIVE

This study examined the association of anxiety alone, depression alone and the presence of both anxiety and depression with preterm birth (PTB) and further examined whether neighbourhood socioeconomic status (SES) modified this association.

DESIGN

Cohort study using individual-level data from two community-based prospective pregnancy cohort studies (All Our Families; AOF) and Alberta Pregnancy Outcomes and Nutrition (APrON) and neighbourhood SES data from the 2011 Canadian census.

SETTING

Calgary, Alberta, Canada.

PARTICIPANTS

Overall, 5538 pregnant women who were <27 weeks of gestation and >15 years old were enrolled in the cohort studies between 2008 and 2012. 3341 women participated in the AOF study and 2187 women participated in the APrON study, with 231 women participated in both studies. Women who participated in both studies were only counted once.

PRIMARY AND SECONDARY OUTCOME MEASURES

PTB was defined as delivery prior to 37 weeks of gestation. Depression was defined as an Edinburgh Postnatal Depression Scale (EPDS) score of ≥13, anxiety was defined as an EPDS-anxiety subscale score of ≥6, and the presence of both anxiety and depression was defined as meeting both anxiety and depression definitions.

RESULTS

Overall, 7.3% of women delivered preterm infants. The presence of both anxiety and depression, but neither of these conditions alone, was significantly associated with PTB (OR 1.6, 95% CI 1.1 to 2.3) and had significant interaction with neighbourhood deprivation (p=0.004). The predicted probability of PTB for women with both anxiety and depression was 10.0%, which increased to 15.7% if they lived in the most deprived neighbourhoods and decreased to 1.4% if they lived in the least deprived neighbourhoods.

CONCLUSIONS

Effects of anxiety and depression on risk of PTB differ depending on where women live. This understanding may guide the identification of women at increased risk for PTB and allocation of resources for early identification and management of anxiety and depression.

Prenatal maternal stress and risk of neurodevelopmental disorders in the offspring: a systematic review and meta-analysis

PURPOSE

Exposure to prenatal stress has been reported to affect the risk of adverse neurodevelopmental outcomes in the offspring; however, there is currently no clear consensus. The aim of this systematic review and meta-analysis was to examine the existing literature on the association between prenatal stress and autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) in the offspring.

METHODS

Based on a registered protocol, we searched several electronic databases for articles in accordance with a detailed search strategy. We performed this study following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).

RESULTS

Prenatal stress was significantly associated with an increased risk of both ASD (pooled OR 1.64 [95% CI 1.15-2.34]; I² = 90%; 15 articles) and ADHD (pooled OR 1.72 [95% CI 1.27-2.34]; I² = 85%; 12 articles).

CONCLUSIONS

This study suggests that prenatal stress may be associated with ASD and ADHD; however, several limitations in the reviewed literature should be noted including significant heterogeneity and there is a need for carefully controlled future studies in this area.

Dynamic and bidirectional associations between maternal stress, anxiety, and social support: The critical role of partner and family support

BACKGROUND

Stress and anxiety in pregnancy and the postpartum period are associated with poor long-term maternal and child health outcomes. Social support has been shown to mitigate the effects of maternal stress and anxiety; however, the directionality and longitudinal associations among these variables are poorly understood. Using a novel multilevel modeling approach called dynamic structural equation modeling (DSEM), we examined within-person (state-level) autoregressive and cross-lagged associations among stress, anxiety, and social support in the perinatal period in order to elucidate directional associations over time.

METHODS

Mothers from a longitudinal pregnancy cohort (N = 3,388) completed self-report measures of stress, anxiety, and social support across 4 time points from pregnancy to 12 months postpartum.

RESULTS

Higher than average levels of stress and anxiety led to elevations in anxiety and stress and decreases in social support at subsequent time points. Importantly, earlier individual levels of partner and family support predicted subsequent decreases in stress and anxiety.

LIMITATIONS

Support was measured via maternal self-report thus extrapolations cannot be made to tangible or instrumental supports and lagged relationships represent average lags over time.

CONCLUSIONS

Using a novel statistical approach, these results suggest that increases in both partner and family support may be powerful protective factors for decreasing mental health difficulties in pregnancy and the postpartum, highlighting the importance of targeting and increasing this type of support from pregnancy to the postpartum period.

Hypertensive Disorders of Pregnancy and Symptoms of Depression and Anxiety as Related to Gestational Age at Birth: Findings From the All Our Families Study

OBJECTIVE

The aim of the study was to investigate whether symptoms of depression or state anxiety changed the strength or nature of the association between hypertensive disorders of pregnancy (HDP) and gestational age at birth.

METHODS

We conducted a secondary analysis of data from the All Our Families Cohort, a prospective pregnancy cohort study based in Calgary, Alberta, Canada. Self-reported depressive symptoms and state anxiety were assessed between 3 and 5 months of gestation, and obstetrical information, including diagnosis of HDP, parity, type of delivery, and gestational age at birth, was retrieved from the maternal discharge abstract. All models were adjusted for sociodemographic and obstetric confounders.

RESULTS

Of 2763 women who had a singleton pregnancy and live birth, 247 (9%) were diagnosed with HDP. Women with HDP had significantly shorter gestational length relative to those without the diagnosis (M = 37.87 versus M = 38.99 weeks of gestation), t(2761) = 9.43, p < .001. Moderation analyses showed significant HDP by depressive symptoms and HDP by state anxiety interactions, such that the strength of the association between HDP and gestational age at birth increased alongside greater depressive symptom and state anxiety severity.

CONCLUSIONS

Results suggest that depressive symptoms and state anxiety may add to the increased risk for shortened gestation associated with HDP. Women at high risk of cardiovascular complications during pregnancy may benefit from additional resources to manage symptoms of depression or anxiety.

Pregnancy-specific anxiety and elective cesarean section in primiparas: A cohort study in China

The purpose of this study was to investigate the association between pregnancy-specific anxiety and elective cesarean section, and identify the critical period in which pregnancy-specific anxiety will affect the elective cesarean section. Primiparous women in the 1^st trimester of pregnancy were invited to participate in the cohort. General information on maternal socio-demographic characteristics and environmental exposure were collected using questionnaires. Pregnancy-specific anxiety was assessed by using pregnancy-specific anxiety questionnaire in the 1^st, 2^nd and 3^rd trimester, respectively. Delivery modes and pregnancy complications were abstracted from medical notes. Structural equation modeling (SEM) was adopted to examine the relationship between pregnancy-specific anxiety and elective cesarean section. Results indicated the overall elective cesarean section rate in this study was 45%. Among 1 874 pregnant women, 30.9% women experienced anxiety at least once during pregnancy, and 6.9% women suffered from anxiety in all three trimesters. Anxiety in the 2^nd trimester was a significant predictor for elective cesarean section. Young maternal age and low educational level had indirect effects on women’s choice of elective caesarean section through affecting pregnancy-specific anxiety. More attention should be paid to maternal psychological problems, and professional counseling needs to be strengthened to protect women from pregnancy-specific anxiety.

Examining postpartum depression screening effectiveness in well child clinics in Alberta, Canada: A study using the All Our Families cohort and administrative data

Affecting 10-15% of women, postpartum depression (PPD) can be debilitating and costly. While early identification has the potential to improve timely care, recommendations regarding the implementation of routine screening are inconsistent. In Alberta, screening is completed using the Edinburgh Postnatal Depression Scale during public health well child clinic visits. The objective of this study was to examine the effectiveness of screening in identifying, diagnosing and treating women at increased risk for PPD over the first year postpartum, compared to those unscreened. The All Our Families prospective pregnancy cohort was linked to public health, inpatient, outpatient, physician claims and community pharmaceutical data over the first year postpartum. Descriptive statistics and bivariate analyses examined differences in sample characteristics and PPD and non-PPD related utilization by screening category. Odds ratios and 95% confidence intervals for PPD diagnosis and mental health drugs dispensed were generated using crude and multivariable logistic regression models. Within our sample, 87% of the eligible population were screened, with 3% receiving a high-risk score, and 13% were unscreened. Compared to those unscreened, women screened high-risk had higher odds of being diagnosed with PPD (OR: 3.88, 95% CI: 2.18-6.92) and women screened low/moderate-risk had reduced odds of receiving a diagnosis (OR: 0.51, 95% CI: 0.35-0.74). High-risk women had an increased likelihood of diagnosis, higher PPD-related utilization and drugs dispensed compared to those unscreened. This information suggests that screening was effective at streamlining resources in Alberta. Future work should focus on evaluating the cost-effectiveness of PPD screening.

Women's recall of health care provider counselling on gestational weight gain (GWG): a prospective, population-based study

BACKGROUND

Prenatal care has been validated to provide medical and educational counselling intended to reduce the risk of adverse pregnancy conditions and improve the maternal and fetal outcomes. Prenatal targeted information regarding nutrition, lifestyle, and weight gain is predictive of meeting Institute of Medicine (IOM) 2009 gestational weight gain (GWG) guidelines. There is limited information about women's experiences with these prenatal counselling domains, particularly in women who do not meet GWG recommendations. The objective of this study was to evaluate the impact of women's recall of prenatal counselling and its effect on meeting their GWG within guidelines in a prospective, community-based pregnancy cohort.

METHODS

A sample of 2909 women with singleton pregnancies was drawn from the prospective community-based pregnancy cohort All Our Families from Alberta, Canada. Women were stratified into three GWG groups, adequate, inadequate, and excessive GWG, based on pre-pregnancy BMI and the adherence to the Institute of Medicine weight gain in pregnancy guidelines. At less than 25 and 34 to 36 weeks' gestation, maternal socio-demographic information and women's recall of prenatal counselling experiences was collected through self-administered questionnaires. Multivariate logistic regression analyses tested GWG strata impact on women's recall of the prenatal counselling advice in eight domains of nutrition, lifestyle, and weight management during pregnancy.

RESULTS

Adequate GWG was reached by 35.9% of women, 46.5% gained excessive and 17.6% gained inadequate weight. Women who were overweight and obese prior to pregnancy were more likely to gain excessive weight than women who were normal weight (OR 3.3, 95% CI 2.6-4.1; and OR 2.9, 95% CI 2.1-3.9, respectively). Most women reported having no difficulties in finding prenatal care, felt comfortable with their health care provider and were satisfied with the answers received. There was no difference in the recall of prenatal advice received in any of the eight domains of prenatal counselling assessed among women with appropriate and non-optimal GWG.

CONCLUSION

Women with adequate and non-optimal GWG received comparable prenatal counselling on nutrition, weight gain, and lifestyle modifications. There remain missed opportunities in targeting prenatal counselling advice to women at risk for suboptimal or excessive GWG.

Trajectories of maternal distress and risk of child developmental delays: Findings from the All Our Families (AOF) pregnancy cohort

BACKGROUND

Existing literature on the impact of the course of maternal distress symptoms in the perinatal period and beyond has mainly focused on one source of distress (e.g., anxiety or depression) and only selected aspects of child development. This study examined the relative impact of trajectories of maternal depression, anxiety, and stress symptoms from mid-pregnancy to early childhood on child communication, gross motor, fine motor, problem solving, and personal social development at three years of age.

METHODS

Data were analyzed from 1983 mother-child dyads who participated in the three-year follow-up of the All Our Families (AOF) study. Maternal distress and child development across five domains were measured using validated tools. Latent class analysis (LCA) was conducted to identify trajectories of maternal distress over time. Multivariable logistic regression was used to explore the relationship between the trajectories and child development while adjusting for the covariates.

RESULTS

At age three years, 5.2% of children were at risk communication delay; 12.7% for gross motor delay; 15.4% for fine motor delay; 11.2 for problem solving delay; and 5.6% for personal-social delay on ASQ-3 domains. Multivariable analysis showed children born to mothers with persistent high anxiety symptoms from pregnancy to 3-years postpartum had an increased risk of delays in communication and personal-social domains.

LIMITATIONS

The use of self-reported maternal mental health symptoms and maternal reported child development are the study limitations.

CONCLUSIONS

The impact of high levels of maternal anxiety symptoms on the increased risk of child developmental delay in communication and personal-social domains highlights the importance of early intervention and addressing maternal anxiety from pregnancy through early childhood.

A Practical Approach for the Verification and Determination of Site- and Trimester-Specific Reference Intervals for Thyroid Function Tests in Pregnancy

BACKGROUND

Population-, assay-, and trimester-specific reference intervals for thyroid function tests are necessary to assess thyroid status accurately and manage thyroid disease throughout pregnancy. This study's objective was to verify if the manufacturer's recommended trimester-specific reference intervals for thyroid tests and the American Thyroid Association's recommended total thyroxine (TT4) pregnancy reference intervals were verifiable and appropriate for use in the authors' multicultural population.

METHODS

Blood samples were obtained from the following sources: stored frozen surplus blood from women undergoing routine aneuploidy screening (first- and second-trimester samples, n = 274), women participating in an observational cohort study (second- and third-trimester samples, n = 135), and blood collected from women presenting for assessment to the labor and delivery ward (third-trimester samples, n = 35). Exclusions included thyroid medication or disease and positive thyroid peroxidase antibodies (anti-TPO). Samples were analyzed for thyrotropin (TSH), free T4 (fT4), free triiodothyronine (fT3), TT4, and anti-TPO using the Roche Cobas 8000 Modular e602 electrochemiluminescence immunoassay.

RESULTS

Nine percent of the aneuploidy screening samples were excluded prior to thyroid testing due to maternal use of thyroid medication. Six percent of analyzed samples were excluded: 5.9% with positive anti-TPO and one with a TSH >10 mIU/L. The manufacturer's recommended trimester-specific reference intervals for TSH were not verified by described standardized methods. Therefore, 95th percentile reference intervals were determined using a minimum number of samples. Reference intervals for TSH and fT4 were as follows: 9-12 weeks, 0.18-2.99 mIU/L and 11-19.2 pmol/L; second trimester, 0.11-3.98 mIU/L and 10.5-18.2 pmol/L; and third trimester, 0.48-4.71 mIU/L and 9.0-16.1 pmol/L, respectively. The TT4 reference interval after 19 weeks' gestation was 77-186 nmol/L.

CONCLUSIONS

This study provides a simple approach to verify or establish trimester-specific thyroid function reference intervals in local populations. The TT4 reference interval was lower than the interval proposed by the American Thyroid Association, suggesting the need for further study of TT4 in pregnancy and reliance on locally established fT4 reference intervals after 19 weeks, especially when there are no equivalent reference intervals for TT4.

Association Between Screen Time and Children's Performance on a Developmental Screening Test

IMPORTANCE

Excessive screen time is associated with delays in development; however, it is unclear if greater screen time predicts lower performance scores on developmental screening tests or if children with poor developmental performance receive added screen time as a way to modulate challenging behavior.

OBJECTIVE

To assess the directional association between screen time and child development in a population of mothers and children.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal cohort study used a 3-wave, cross-lagged panel model in 2441 mothers and children in Calgary, Alberta, Canada, drawn from the All Our Families study. Data were available when children were aged 24, 36, and 60 months. Data were collected between October 20, 2011, and October 6, 2016. Statistical analyses were conducted from July 31 to November 15, 2018.

EXPOSURES

Media.

MAIN OUTCOMES AND MEASURES

At age 24, 36, and 60 months, children's screen-time behavior (total hours per week) and developmental outcomes (Ages and Stages Questionnaire, Third Edition) were assessed via maternal report.

RESULTS

Of the 2441 children included in the analysis, 1227 (50.2%) were boys. A random-intercepts, cross-lagged panel model revealed that higher levels of screen time at 24 and 36 months were significantly associated with poorer performance on developmental screening tests at 36 months (β, -0.06; 95% CI, -0.10 to -0.01) and 60 months (β, -0.08; 95% CI, -0.13 to -0.02), respectively. These within-person (time-varying) associations statistically controlled for between-person (stable) differences.

CONCLUSIONS AND RELEVANCE

The results of this study support the directional association between screen time and child development. Recommendations include encouraging family media plans, as well as managing screen time, to offset the potential consequences of excess use.

Does neighborhood socioeconomic status predict the risk of preterm birth? A community-based Canadian cohort study

OBJECTIVE

This study developed and internally validated a predictive model for preterm birth (PTB) to examine the ability of neighbourhood socioeconomic status (SES) to predict PTB.

DESIGN

Cohort study using individual-level data from two community-based prospective pregnancy cohort studies (All Our Families (AOF) and Alberta Pregnancy Outcomes and Nutrition (APrON)) and neighbourhood SES data from the 2011 Canadian census.

SETTING

Calgary, Alberta, Canada.

PARTICIPANTS

Pregnant women who were <24 weeks of gestation and >15 years old were enrolled in the cohort studies between 2008 and 2012. Overall, 5297 women participated in at least one of these cohorts: 3341 women participated in the AOF study, 2187 women participated in the APrON study and 231 women participated in both studies. Women who participated in both studies were only counted once.

PRIMARY AND SECONDARY OUTCOME MEASURES

PTB (delivery prior to 37 weeks of gestation).

RESULTS

The rates of PTB in the least and most deprived neighbourhoods were 7.54% and 10.64%, respectively. Neighbourhood variation in PTB was 0.20, with an intra-class correlation of 5.72%. Neighbourhood SES, combined with individual-level predictors, predicted PTB with an area under the receiver-operating characteristic curve (AUC) of 0.75. The sensitivity was 91.80% at a low-risk threshold, with a high false-positive rate (71.50%), and the sensitivity was 5.70% at a highest risk threshold, with a low false-positive rate (0.90%). An agreement between the predicted and observed PTB demonstrated modest model calibration. Individual-level predictors alone predicted PTB with an AUC of 0.60.

CONCLUSION

Although neighbourhood SES combined with individual-level predictors improved the overall prediction of PTB compared with individual-level predictors alone, the detection rate was insufficient for application in clinical or public health practice. A prediction model with better predictive ability is required to effectively find women at high risk of preterm delivery.

Mitigation of Participant Loss to Follow-Up Using Facebook: All Our Families Longitudinal Pregnancy Cohort

BACKGROUND

Facebook, a popular social media site, allows users to communicate and exchange information. Social media sites can also be used as databases to search for individuals, including cohort participants. Retaining and tracking cohort participants are essential for the validity and generalizability of data in longitudinal research. Despite numerous strategies to minimize loss to follow-up, maintaining contact with participants is time-consuming and resource-intensive. Social media may provide alternative methods of contacting participants who consented to follow-up but could not be reached, and thus are potentially "lost to follow-up."

OBJECTIVE

The aim of this study was to determine if Facebook was a feasible method for identifying and contacting participants of a longitudinal pregnancy cohort who were lost to follow-up and re-engaging them without selection bias.

METHODS

This study used data from the All Our Families cohort. Of the 2827 mother-child dyads within the cohort, 237 participants were lost to follow-up. Participants were considered lost to follow-up if they had agreed to participate in additional research, completed at least one of the perinatal questionnaires, did not complete the 5-year postpartum questionnaire, and could not be contacted after numerous attempts via phone, email, or mail. Participants were considered to be matched to a Facebook profile if 2 or more characteristics matched information previously collected. Participants were sent both a friend request and a personal message through the study's Facebook page and were invited to verify their enrollment in the study. The authors deemed a friend request was necessary because of the reduced functionality of nonfriend direct messaging at the time. If the participant accepted the study's friend request, then a personalized message was sent. Participants were considered reconnected if they accepted the friend request or responded to any messages. Participants were considered re-engaged if they provided up-to-date contact information.

RESULTS

Compared with the overall cohort, participants who were lost to follow-up (n=237) were younger (P=.003), nonmarried (P=.02), had lower household income (P<.001), less education (P<.001), and self-identified as being part of an ethnic minority (P=.02). Of the 237 participants considered lost to follow-up, 47.7% (113/237) participants were identified using Facebook. Among the 113 identified participants, 77.0% (87/113) were contacted, 32.7% (37/113) were reconnected, and 17.7% (20/113) were re-engaged. No significant differences were found between those identified on Facebook (n=113) and those who were not able to be identified (n=124).

CONCLUSIONS

Facebook identified 47.6% (113/237) of participants who were considered lost to follow-up, and the social media site may be a practical tool for reconnecting with participants. The results from this study demonstrate that social networking sites, such as Facebook, could be included in the development of retention practices and can be implemented at any point in cohort follow-up.

Prenatal maternal stress and risk of neurodevelopmental disorders in the offspring: A systematic review and meta-analysis protocol

Background: Prenatal maternal stress (PNMS) is defined as the experience of significant levels of prenatal stress, depression or anxiety during pregnancy. PNMS has been associated with increased risk of autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) in exposed offspring. However, these findings are inconsistent and other studies found no association, meaning a clear consensus on the impact of PNMS on ASD and ADHD risk is required. The purpose of this systematic review and meta-analysis is to summarize and critically review the existing literature on the effects of PNMS on ASD and ADHD risk. Methods: Electronic databases (PubMed, PsycINFO, Web of Science, Scopus and EMBASE) will be searched for articles following a detailed search strategy. We will include cohort and case-control studies that assessed maternal exposure to psychological and/or environmental stress and had ASD or ADHD as an outcome. Two reviewers will independently screen the titles, abstracts and full articles to identify eligible studies. We will use a standardised data extraction form for extracting data and a bias classification tool for assessing study quality. This systematic review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). The generic inverse variance method will be used if possible to perform meta-analyses. Ethics and dissemination: Ethical approval is not required for this study because it will not involve the conduct or inclusion of any experimental or personal data that would require informed consent.  The systematic review will be disseminated in peer-reviewed journals. PROSPERO registration number: CRD42018084222.

Maternal perceptions of childhood vaccination: explanations of reasons for and against vaccination

BACKGROUND

Understanding reasons for and against vaccination from the parental perspective is critical for designing vaccination campaigns and informing other interventions to increase vaccination uptake in Canada. The objective of this study was to understand maternal vaccination decision making for children.

METHODS

Mothers participating in a longitudinal community-based pregnancy cohort, the All Our Babies study in Calgary, Alberta, completed open-ended survey questions providing explanations for the vaccination status of their child by 24 months postpartum. Qualitative responses were linked to administrative vaccination records to examine survey responses and recorded child vaccination status.

RESULTS

There were 1560 open-ended responses available; 89% (n = 1391) provided explanations for vaccinating their children, 5% (n = 79) provided explanations for not vaccinating/delaying, and 6% (n = 90) provided explanations for both. Themes were similar for those vaccinating and not vaccinating/delaying; however, interpretations were different. Two broad themes were identified: Sources of influence and Deliberative Processes. Sources of influence on decision making included personal, family, and external experiences. Deliberative Processes included risk, research, effectiveness, and balancing risks/benefits. Under Deliberative Processes, responsibility was a category for those vaccinating; while choice, instrumental/practical, and health issues were categories for those not vaccinating/delaying. Mothers' levels of conviction and motivation provided a Context for understanding their decision making perspectives.

CONCLUSIONS

Vaccination decision making is complex and impacted by many factors that are similar but contribute to different decisions depending on mothers' perspectives. The results of this study indicate the need to examine new intervention approaches to increase uptake that recognize and address feelings of pressure and parental commitment to choice.

Supporting healthy pregnancies: Examining variations in nutrition, weight management and substance abuse advice provision by prenatal care providers in Alberta, Canada. A study using the All Our Families cohort

Background

Pregnancy is a critical time for fetal development, and education of women regarding healthy lifestyle choices is an important function for prenatal care providers, those that provide care to women during pregnancy. Within Canada, women choose to receive pregnancy care from one of a variety of publicly funded care providers. This study examines the association between the type of care provider(s) seen during pregnancy and the provision of advice related to nutrition, weight management and substance abuse.

Methods

Using data from the Alberta-based All Our Families prospective pregnancy cohort, we conducted bivariate and multivariate analyses to determine the likelihood of receiving advice related to nutrition, weight management, and substance abuse across provider(s) seen.

Results

Of 3341 women in our sample, 38% saw a single provider during pregnancy and 56% received care from multiple providers. Advice on nutrition was more likely to be provided across all providers, while weight management and substance abuse was less frequently and less consistently discussed. Relative to doctors in low-risk maternity clinics, midwives were most likely to provide nutrition (OR: 3.09, 95% CI: 1.19–8.01) and weight management (OR: 1.99, 95% CI: 1.13–3.50) advice to women.

Conclusion

Findings suggest that the type of prenatal advice received by women depends on the provider(s) seen during pregnancy. Substance abuse was least likely to be discussed across providers, suggesting important implications given recent cannabis legalization.

Prediction and Understanding of Resilience in Albertan Families: Longitudinal Study of Disaster Responses (PURLS) - Protocol

Exposure to a natural disaster in childhood can have serious, long-lasting consequences, impacting physical and mental health, development, and learning. Although many children experience negative effects after a disaster, the majority do not, and what differentiates these groups is not well understood. Some of the factors that influence disaster-related outcomes in the midst of adversity include parents' mental health, the home environment, and socioeconomic status. Furthermore, genetics has also a role to play in how children respond to stressors. We had the opportunity to conduct a natural experiment of disaster recovery following the Alberta 2013 Flood. This paper presents the detailed protocol on prediction of resilience in Albertan families, and validation with cortisol data. In addition, data collection procedures, developing resiliency screening tools, candidate gene identification, genotyping, DNA methylation, and genomic analyses are described to achieve the research objectives. This study produced new knowledge by using pre- and post-disaster information on children's health and development, including children's genetics and responses to stress. This information has been identified as important to governments and other organizations invested in early child development. Our comprehensive research plan generates evidence that can be mobilized population-based approaches to improve child and family resiliency.

Maternal adverse childhood experiences, mental health, and child behaviour at age 3: The all our families community cohort study

Links between adverse childhood experiences (ACEs) and threats to health and well-being later in life are well established. The current study extends those findings into younger populations of pregnant women and their children; investigating how ACEs relates to maternal postpartum well-being, coping, and parenting, as well as child outcomes. Participants included 1994 mothers and children from the All Our Families community-based cohort in Alberta, Canada, followed from pregnancy (from 2008 to 2011) until child age 3 years. The sample is representative of the pregnant population in an urban Canadian centre. Mothers completed questionnaires on ACEs, postpartum mental health, as well as parenting morale, efficacy, coping, and personality. Child outcomes included internalizing and externalizing behavior, as well as temperament. Approximately 62% of participants experienced at least one ACE; 25% experienced 3 or more ACEs. The presence of 3 or more ACEs was associated with postpartum smoking, binge drinking, depressive and anxiety symptoms, lower optimism and higher neuroticism, and lower reported parenting morale. In children, 3 or more maternal ACEs was associated with higher levels of internalizing (e.g., anxiety) and externalizing difficulties (aggression and hyperactivity), as well as temperament (surgency and negative affectivity). Cumulative maternal ACEs are associated with postpartum mental health and parenting morale, as well as maladaptive coping strategies. The demonstrated downstream consequences of maternal ACEs for child outcomes suggests that early intervention strategies and community resources to improve life course outcomes for parents and children are critical for breaking intergenerational continuities of risk.

Maternal adverse childhood experiences and antepartum risks: the moderating role of social support

The aims of the current study were to examine the association between maternal adverse childhood experiences (ACEs) and antepartum health risks, and to investigate whether social support moderated this association. It was hypothesized that ACEs would be associated with antepartum health risks; however, social support in the prenatal period would buffer mothers from the deleterious consequences of ACEs. Data from 1994 women (mean age = 31 years) and their infants were collected from a longitudinal cohort recruited in health care offices in Alberta, Canada. Pregnant women completed questionnaires related to ACEs prior to the age of 18 and prenatal social support, and a health care professional assessed the mother's antepartum health risk. ACEs included physical, emotional, and sexual abuse, exposure to domestic violence, as well as exposure to household dysfunction such as parental substance use, mental illness, or incarceration. Regression analyses demonstrated a positive association between ACEs and antepartum health risks. However, a significant interaction between maternal ACEs and social support was also observed. Specifically, women exposed to high ACEs and low social support in pregnancy had high antepartum health risks. However, among mothers who had high ACEs but also high levels of social support, there was no association between ACEs and antepartum health risk. A history of ACEs can place mothers at risk of antepartum health complications. However, a resiliency effect was observed: women with a history of ACEs were buffered from experiencing antepartum health risks if they reported high levels of social support in pregnancy.

Sharing longitudinal, non-biological birth cohort data: a cross-sectional analysis of parent consent preferences

BACKGROUND

Mandates abound to share publicly-funded research data for reuse, while data platforms continue to emerge to facilitate such reuse. Birth cohorts (BC) involve longitudinal designs, significant sample sizes and rich and deep datasets. Data sharing benefits include more analyses, greater research complexity, increased opportunities for collaboration, amplification of public contributions, and reduced respondent burdens. Sharing BC data involves significant challenges including consent, privacy, access policies, communication, and vulnerability of the child. Research on these issues is available for biological data, but these findings may not extend to BC data. We lack consensus on how best to approach these challenges in consent, privacy, communication and autonomy when sharing BC data. We require more stakeholder engagement to understand perspectives and generate consensus.

METHODS

Parents participating in longitudinal birth cohorts completed a web-based survey investigating consent preferences for sharing their, and their child's, non-biological research data. Results from a previous qualitative inquiry informed survey development, and cognitive interviewing methods (n = 9) were used to improve the question quality and comprehension. Recruitment was via personalized email, with email and phone reminders during the 14-day window for survey completion.

RESULTS

Three hundred and forty-six of 569 parents completed the survey in September 2014 (60.8%). Participants preferred consent processes for data sharing in future independent research that were less-active (i.e. no consent or opt-out). Parents' consent preferences are associated with their communication preferences. Twenty percent (20.2%) of parents generally agreed that their child should provide consent to continue participating in research at age 12, while 25.6% felt decision-making on sharing non-biological research data should begin at age 18.

CONCLUSIONS

These finding reflect the parenting population's preference for less project-specific permission when research data is non-biological and de-identified and when governance practices are highly detailed and rigourous. Parents recognize that children should become involved in consent for secondary data use, but there is variability regarding when and how involvement occurs. These findings emphasize governance processes and participant notification rather than project-specific consent for secondary use of de-identified, non-biological data. Ultimately, parents prefer general consent processes for sharing de-identified, non-biological research data with ultimate involvement of the child.

The Healthy Pregnancy Research Program: transforming pregnancy research through a ResearchKit app

Although maternal morbidity and mortality in the US is among the worst of developed countries, pregnant women have been under-represented in research studies, resulting in deficiencies in evidence-based guidance for treatment. There are over two billion smartphone users worldwide, enabling researchers to easily and cheaply conduct extremely large-scale research studies through smartphone apps, especially among pregnant women in whom app use is exceptionally high, predominantly as an information conduit. We developed the first pregnancy research app that is embedded within an existing, popular pregnancy app for self-management and education of expectant mothers. Through the large-scale and simplified collection of survey and sensor generated data via the app, we aim to improve our understanding of factors that promote a healthy pregnancy for both the mother and developing fetus. From the launch of this cohort study on 16 March 2017 through 17 December 2017, we have enrolled 2058 pregnant women from all 50 states. Our study population is diverse geographically and demographically, and fairly representative of US population averages. We have collected 14,045 individual surveys and 107,102 total daily measurements of sleep, activity, blood pressure, and heart rate during this time. On average, women stayed engaged in the study for 59 days and 45 percent who reached their due date filled out the final outcome survey. During the first 9 months, we demonstrated the potential for a smartphone-based research platform to capture an ever-expanding array of longitudinal, objective, and subjective participant-generated data from a continuously growing and diverse population of pregnant women.

Trajectories of maternal stress and anxiety from pregnancy to three years and child development at 3 years of age: Findings from the All Our Families (AOF) pregnancy cohort

BACKGROUND

Existing literature on maternal distress has focused on stress and anxiety during the pregnancy or postnatally and their relationship with child development. However, few studies have investigated the association between maternal stress and anxiety symptoms over time and child development in preschool children. The aim of this study was to examine the association between trajectories of maternal stress and anxiety symptoms from mid-pregnancy to three years postpartum and child development at age three years.

METHODS

Data were analyzed from 1983 mother-child dyads who participated in the three year follow-up of the All Our Families (AOF) study. Latent class analysis (LCA) was conducted to identify trajectories of women's stress and anxiety across from mid-pregnancy to three years postpartum. Multivariate logistic regression was used to explore the relationship between the stress and anxiety trajectories and child developmental delays while adjusting for the covariates.

RESULTS

LCA identified three distinct trajectories of maternal stress and anxiety symptoms over time. Multivariate analysis showed mothers assigned to the high anxiety symptoms class had an increased risk (adjusted OR 2.80, 95% CI 2.80 (1.42 ─ 5.51), p = 0.003) of having a child with developmental delays at 3 years.

LIMITATIONS

The use of self-reported maternal mental health symptoms and no data on fathers' mental health are our study's limitations.

CONCLUSIONS

The findings from a population-based Canadian sample provide empirical support for a relationship between maternal anxiety overtime and risk of child developmental delays. Identifying and supporting mothers experiencing high anxiety symptoms in the perinatal period may mitigate the risk of these delays in children.

Prenatal maternal stress and risk of neurodevelopmental disorders in the offspring: A systematic review and meta-analysis protocol

Background: Prenatal maternal stress (PNMS) is defined as the experience of significant levels of prenatal stress, depression or anxiety during pregnancy. PNMS has been associated with increased risk of autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) in exposed offspring. However, these findings are inconsistent and other studies found no association, meaning a clear consensus on the impact of PNMS on ASD and ADHD risk is required. The purpose of this systematic review and meta-analysis is to summarize and critically review the existing literature on the effects of PNMS on ASD and ADHD risk. Methods: Electronic databases (PubMed, PsycINFO, Web of Science, Scopus and EMBASE) will be searched for articles following a detailed search strategy. We will include cohort, case-control and cross-sectional studies that assessed maternal exposure to psychological and/or environmental stress and had ASD or ADHD as an outcome. Two reviewers will independently screen the titles, abstracts and full articles to identify eligible studies. We will use a standardised data extraction form for extracting data and a bias classification tool for assessing study quality. This systematic review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). The generic inverse variance method will be used if possible to perform meta-analyses. Ethics and dissemination: Ethical approval is not required for this study because it will not involve the conduct or inclusion of any experimental or personal data that would require informed consent.  The systematic review will be disseminated in peer-reviewed journals. PROSPERO registration number: CRD42018084222.

The Ontario Birth Study: A prospective pregnancy cohort study integrating perinatal research into clinical care

BACKGROUND

Pregnancy and early childhood represent critical periods that impact health throughout the life-course. The Ontario Birth Study (OBS) is a pregnancy cohort study designed as a platform for research on pregnancy complications, maternal and infant health, and the developmental origins of health and disease.

METHODS

Pregnant women <17 weeks gestational age were recruited between 2013 and 2015 from antenatal clinics at Mount Sinai Hospital, Toronto, Canada. Life style and diet questionnaires, biospecimens, and clinical data were collected throughout the pregnancy and postpartum period at the time of clinical care. The OBS was integrated into clinical care to reduce participant burden, improve efficiency, and increase research potential.

RESULTS

There were 3181 eligible women approached for recruitment and 1374 (43%) participated in the study. Among the 1374 participants, 1272 (93%) delivered a liveborn infant and were followed to 6-10 weeks postpartum. Of the 1272 women who completed the study, 98% had at least one pregnancy blood sample collected, 97% had vaginal swabs collected, 90% completed the prenatal life style questionnaires, and 78% completed the Diet History Questionnaire. Most women (88%) were ≥30 years of age, 55% had no previous children, 24% were overweight or obese pre-pregnancy and 78% of parents had postsecondary education. Most pregnancies were singleton (3% twins), 34% delivered by caesarean section, and 6% preterm (<37 weeks gestation).

CONCLUSIONS

The OBS is a contemporary cohort with detailed data including banked biospecimens for studies of pregnancy health and the gene-environment interactions that establish developmental trajectories to health, learning, and social functioning.

Recall of Prenatal Counselling Among Obese and Overweight Women from a Canadian Population: A Population Based Study

Objective The objective of this study was to evaluate the recall of prenatal counselling received among overweight and obese women in primary care settings. Methods A sample of 1996 women with singleton, term deliveries and pre-pregnancy BMI >18.5 kg/m² were identified from the All Our Babies pregnancy cohort. Information on socio-demographic characteristics and women's experiences with prenatal counselling on nutrition, vitamin and mineral supplements, exercise, weight gain, employment, alcohol and drug use, and smoking during pregnancy were collected through questionnaires administered at <25 weeks and 34-36 weeks gestation. Multivariable logistic regression analyses explored the associations between pre-pregnancy BMI and the domains of prenatal counselling, controlling for confounders. Results Women reported high levels of comfort asking questions and satisfaction with their health care provider. Women reported getting information about nutrition (69.3%), weight gain (67.8%), exercise (64.4%), vitamins and minerals supplementation (86.1%). Obese women (211, 10.6%) were more likely than normal weight women (1313, 65.8%) to be Caucasian (p = 0.004), less educated (p = 0.001), and to have been born or lived in Canada for at least 5 years (p = 0.01). There was no difference in the prenatal advice received on nutrition, weight gain and exercise in pregnancy between obese, overweight, and normal weight women. Conclusions for Practice Pre-pregnancy BMI did not appear to influence the recall of prenatal counselling women receive in community health care centers. Given the importance of nutrition and weight gain during pregnancy, and guidelines for weight gain based on pre-pregnancy BMI, there are missed opportunities in knowledge exchange between women and providers in the prenatal period.

The impact of time since vaccination and study design on validity in parental recall of childhood vaccination status in the All Our Families cohort

INTRODUCTION

Parental reporting of childhood vaccination status is often used for policy and program evaluation and research purposes. Many factors can bias parental reporting of childhood vaccination status, however, to our knowledge, no analysis has assessed whether time since vaccination impacts reporting accuracy. Therefore, using the Calgary electronic vaccine registry (PHANTIM) as the gold standard, we aimed to test the accuracy of parental reporting of childhood vaccination status at three different time-points since vaccination.

METHODS

The All Our Families (AOF) cohort study asked parents to report their child's 2, 4, 6, 12 and 18 month vaccines (vaccination time-point) on questionnaires given when the child was 1, 2 and 3 years of age (survey time-point). We linked the AOF parental reporting of vaccination status to the PHANTIM registry and calculated the percent agreement and difference in coverage estimates between PHANTIM and AOF at each vaccination and survey time-point combination. Furthermore, we measured the sensitivity and specificity, and negative (NPV) and positive predictive values (PPV) of parental vaccine recall across time.

RESULTS

AOF parent reports of coverage rates were consistently higher than the PHANTIM estimates. While we saw significant differences in percent agreement for certain vaccination time-points, we saw no consistent directional difference by survey time-point, suggesting that parental accuracy did not change with time. We found a uniformly high sensitivity across all vaccination and survey time-points, and no consistent patterns in the specificity, PPV and NPV results.

CONCLUSION

Time since vaccination may not be the most important consideration when designing and implementing a vaccination survey. Other factors that may contribute to the bias associated with parental reporting of vaccination status include the complexity of the vaccine schedule, schedule changes over time, and the wording and structure of the questionnaires.

Trajectories of maternal depressive symptoms during pregnancy and the first 12 months postpartum and child externalizing and internalizing behavior at three years

Background

Most evidence of the association between maternal depression and children’s development is limited by being cross-sectional. To date, few studies have modelled trajectories of maternal depressive symptoms from pregnancy through the early postpartum years and examined their association with social emotional and behavior functioning in preschool children. The objectives of this study were to: 1) identify distinct groups of women defined by their trajectories of depressive symptoms across four time points from mid-pregnancy to one year postpartum; and 2) examine the associations between these trajectories and child internalizing and externalizing behaviors.

Methods

We analyzed data from the All Our Families (AOF) study, a large, population based pregnancy cohort of mother-child dyads in Alberta, Canada. The AOF study is an ongoing pregnancy cohort study designed to investigate relationships between the prenatal and early life period and outcomes for children and mothers. Maternal depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale. Children’s behavioral functioning at age 3 was assessed using the Behavior Scales developed for the Canadian National Longitudinal Survey of Children and Youth. Longitudinal latent class analysis was conducted to identify trajectories of women’s depressive symptoms across four time points from pregnancy to 1 year postpartum. We used multivariable logistic regression to assess the relationship between trajectories of maternal depressive symptoms and children’s behavior, while adjusting for other significant maternal, child and psychosocial factors.

Results

1983 participants met eligibility criteria. We identified four distinct trajectories of maternal depressive symptoms: low level (64.7%); early postpartum (10.9%); subclinical (18.8%); and persistent high (5.6%). In multivariable models, the proportion of children with elevated behavior symptoms was highest for children whose mothers had persistent high depressive symptoms, followed by mothers with moderate symptoms (early postpartum and subclinical trajectories) and lowest for minimal symptoms. After accounting for demographic, child and psychosocial factors, the relationships between depression trajectories and child hyperactivity/inattention, physical aggression (subclinical trajectory only) and separation anxiety symptoms remained significant.

Conclusion

These findings suggest both externalizing and internalizing children’s behaviors are associated with prolonged maternal depressive symptoms. There is a good case for the need to move beyond overly simplistic clinical cutoff approaches of depressed/not depressed in screening for perinatal depression. Women with elevated depressive symptoms at clinical and subclinical levels need to be identified, provided with evidence-based treatment, and monitored with repeat screening to improve maternal mental health outcomes and reduce the risk of associated negative outcomes on children’s early social-emotional and behavior development.

Examining the Psychometric Properties of Three Standardized Screening Tools in a Pregnant and Parenting Population

Significance Although standardized tools such as the Speilberger State Anxiety scale (1970) and Cohen's Perceived Stress Index (1983) have often been used in pregnant and postpartum populations to evaluate psychosocial risk, there exists very little literature on the reliability of these scales in this population. Given the potentially grave consequences of undiagnosed pre and postpartum mental distress, it is of paramount importance that the tools that are commonly used are evaluated for their psychometric properties within the pregnant and parenting population. Methods The psychometric properties of three mental health scales were evaluated using the All Our Babies data. The All Our Babies cohort is a prospective longitudinal study based in Calgary, Alberta. A total of 3300 women were recruited from prenatal care sites from all four quadrants of the city. Participants were mailed questionnaires at 24-26 weeks gestation, 34-36 weeks and at 4 months postpartum. Reliability for the Speilberger State Anxiety Scale, the Perceived Stress Index and the Life Optimism Test-revised were evaluated by calculating Cronbach's alphas. Validity with related constructs were tested for the State Anxiety Scale and the Perceived Stress Index by calculating Pearson Correlation Coefficients with closely related constructs. Sample size varied from 2670 to 3376, according to the response rate and time point. Depression as a related construct was evaluated using the Edinburgh Postpartum Depression Scale. Results The Cronbach's Alphas for the Speilberger State Anxiety scale were 0.92, 0.92 and 0.93 for 24-26 weeks, 34-36 weeks and 4 months postpartum respectively. The Alpha's for the Perceived Stress index were 0.88, 0.88 and 0.89 respectively. The Life Optimism Test Revised was only measured in the third trimester and the Cronbach's alpha was 0.83. The Pearson Correlation Coefficient for Anxiety with depression were r = 0.73, r = 0.72 and r = 0.77 respectively. The coefficients for stress and depression were r = 0.75, r = 0.75 and r = 0.77 respectively. Discussion/Conclusion The psychometric properties for all three scales were strong, with alphas that were comparable or higher to literature values. These data provide evidence that the use of these scales, previously validated in other populations are appropriate for use in among pregnant and parenting women at risk for mental distress.

Relationship Between Psychosocial Distress in Pregnancy and Two Genes Associated With Human Social Interaction: A Pilot Study

Background

Prenatal depression, anxiety, and stress (prenatal psychosocial distress) are common, and several environmental risk factors have been implicated in their development. Variation in genes, specifically single nucleotide polymorphisms (SNPs), may explain why some women develop maternal mental health concerns while others do not.

Purpose

The purpose of this pilot study was to determine the feasibility of completing SNP analyses using whole blood collected prenatally between 2008 and 2011. We examined the association between SNPs in two genes (FKBP5 and OXTR) among women with low and high prenatal psychosocial distress.

Methods

A subset (N = 50, 25 high and 25 low prenatal psychosocial distress) of participants was selected from the All Our Families pregnancy cohort. DNA was extracted from maternal blood and used for selected SNP analysis. Participants’ scores on the Edinburgh Prenatal Depression Scale, Spielberger State Anxiety Inventory, and Perceived Stress Scale were used along with demographic variables.

Results

Genotype distribution was not significantly different between the low and high prenatal psychosocial distress groups for either the FKBP5 or the OXTR SNP (p = .699 and p = .125). After controlling for maternal age and income, women with the GG genotype at the OXTR SNP (rs237885) were statistically less likely to be in the high prenatal psychosocial distress group (p = .037).

Conclusion

OXTR SNP rs237885, maternal age, and lower income were associated with prenatal psychosocial distress. This pilot study demonstrated the feasibility of continuing to a larger study that incorporates additional environmental and genetic information.

Differential Associations of Adverse Childhood Experience on Maternal Health

INTRODUCTION

The current study examined whether three distinct antecedent factors related to maternal adverse childhood experiences were differentially associated with maternal health and psychosocial outcomes in the antepartum period. It was hypothesized that all three adverse childhood experience factors would be positively associated with poor health prior to pregnancy, poor reproductive health history, and health complications and psychosocial difficulties during pregnancy.

METHODS

Data from 1,994 women (mean age=30.87 years) and their infants were collected from a prospective longitudinal cohort from 2008 to 2011. Pregnant women completed self-report questionnaires and a healthcare professional assessed the mothers' health prior to pregnancy, reproductive history, and pregnancy complications.

RESULTS

Data analyses were conducted from December 2016 to March 2017. Path analysis demonstrated that women who had experience with physical/emotional abuse in childhood were significantly more likely to enter pregnancy with a chronic health condition (AOR=1.25, 95% CI=1.02, 1.54) and to have psychosocial difficulties in their pregnancy (AOR=1.60, 95% CI=1.34, 1.89). Women who were exposed to household dysfunction in childhood were also significantly more likely to experience psychosocial difficulties during pregnancy (AOR=2.33, 95% CI=1.49, 3.65). There was no association between exposure to sexual abuse and maternal health or mental health outcomes.

CONCLUSIONS

Adverse childhood experience categories differentially predicted maternal health and psychosocial outcomes prior to and during pregnancy. The overall variance accounted for by adverse childhood experiences was small (3%-19%), suggesting that factors other than childhood adversity likely contribute to maternal health.

Patterns of change in anxiety and depression during pregnancy predict preterm birth

BACKGROUND

To determine whether changes in anxiety and depression during pregnancy influence the risk of having a preterm birth (PTB), and whether chronic stress modifies this relationship.

METHODS

The data source for the current study is the All Our Babies prospective cohort (AOB). Anxiety and depression were measured at 17-24 weeks and again at 32-36 weeks' gestation using the Spielberg State Anxiety Scale and the Edinburgh Postnatal Depression Scale, respectively. Chronic stress was assessed at 17-24 weeks' gestation as a potential covariate, and was measured using the Perceived Stress Scale. Multivariable logistic regression modeling was used to assess each relationship RESULTS: Women who experienced an increase in anxiety scores, (time point 32-36 weeks, compared to the earlier time point 17-24 weeks), had 2.70 times higher odds of preterm delivery, compared to those with a reduction in anxiety scores (95% CI 1.28, 5.69). Consistent low or high depression scores did not significantly influence the odds of PTB compared to a decrease in depression scores. A co-occurring increase in anxiety and depression scores was not found to increase the risk of PTB, and chronic stress did not modify any of these relationships.

LIMITATIONS

This study was limited by a relatively small sample of women who delivered preterm, and therefore it was not possible to conduct additional analyses. Further, the analyses were limited to mostly late preterm infants (32-36 weeks' gestation).

CONCLUSIONS

These findings should be validated with additional cohorts and a larger sample size. Ultimately, primary prevention could address anxiety during pregnancy.

Maternal distress in late pregnancy alters obstetric outcomes and the expression of genes important for placental glucocorticoid signalling

The experience of maternal distress in pregnancy is often linked with poorer obstetric outcomes for women as well as adverse outcomes for offspring. Alterations in placental glucocorticoid signalling and subsequent increased fetal exposure to cortisol have been suggested to underlie this relationship. In the current study, 121 pregnant women completed the Perceived Stress Scale, State Trait Anxiety Inventory and Edinburgh Postnatal Depression Scale in the third trimester of pregnancy. Placental samples were collected after delivery. Maternal history of psychiatric illness and miscarriage were significant predictors of poorer mental health in pregnancy. Higher anxiety was associated with an increase in women delivering via elective Caesarean Section, and an increase in bottle-feeding. Birth temperature was mildly reduced among infants of women with high levels of depressive symptomology. Babies of mothers who scored high in all stress (cumulative distress) measures had reduced 5-min Apgar scores. High cumulative distress reduced the expression of placental HSD11B2 mRNA and increased the expression of placental NR3C1 mRNA. These data support a role for prenatal distress as a risk factor for altered obstetric outcomes. The alterations in placental gene expression support a role for altered placental glucocorticoid signalling in the relationship between maternal prenatal distress and adverse outcomes.

Risk and Protective Factors for Mental Health and Community Cohesion After the 2013 Calgary Flood

OBJECTIVE

To examine mental health and community cohesion in women living in Calgary after a natural disaster considering previously collected mental health data.

METHODS

Data from an ongoing longitudinal cohort, the All Our Families study, were used to examine mental health and community cohesion 5 months after a major flood in Calgary, Canada. Participants who had completed a baseline questionnaire before the flood were eligible for inclusion in this study (N=923). Four multivariable logistic regression models were built to examine predictors of post-traumatic stress, depression, anxiety, and community cohesion.

RESULTS

Elevated anxiety before the flood was associated with 2.49 (95% CI: 1.17, 5.26) increased odds of experiencing high levels of post-traumatic stress, regardless of whether respondents lived in a flood-risk community or not. Women who experienced damage to property, or who provided help to others, were more likely to perceive an increased sense of community cohesion (adjusted ods ratio (AOR): 1.67; 95% CI: 1.09, 2.54 and AOR: 1.68; 95% CI: 1.13, 2.52, respectively).

CONCLUSIONS

Women with underlying mental health conditions may be more vulnerable to the psychological impacts of a natural disaster regardless of their level of exposure. Natural disasters may bring communities together, especially those who were more tangibly impacted. (Disaster Med Public Health Preparedness. 2018;12:470-477).

Timeliness and completeness of routine childhood vaccinations in children by two years of age in Alberta, Canada

OBJECTIVES

Assessing timeliness and completeness of vaccine administration is important for evaluating the effectiveness of immunization programs. Few studies have reported timeliness, particularly in Canada. The objective of this study was to examine timeliness of the receipt of vaccination for each routine childhood recommended vaccine by 24 months of age among children in a community-based pregnancy cohort in Calgary, Alberta.

METHODS

Survey data from a community-based pregnancy cohort in Alberta were linked to Public Health vaccination records of children (n = 2763). The proportion of children receiving early, timely, delayed, or no vaccination was calculated. A dose was considered early if it was administered before the recommended age in days as per the vaccination schedule, timely if administered at any time from start of recommended age in days to age in days when delay counts were initiated, and delayed if it was administered on or after age in days when delay counts were initiated. Series completion rates were also calculated.

RESULTS

For multi-dose vaccines, over 80% of children had timely doses at 2, 4 and 6 months. By 12 months, this proportion decreased to 65% (95% CI: 63%-66%) for meningococcal conjugate group C, 61% (95% CI: 59%-62%) for measles antigen-containing vaccines and 64% (95% CI: 62%-65%) for varicella antigen-containing vaccines. At 18 months, only 55% (95% CI: 53%-56%) of the children had a timely 4th dose of diphtheria, acellular pertussis, tetanus, polio, and Haemophilus influenzae type b vaccine. Eventual series completion rate for all recommended vaccines was 77% (95% CI: 75%-79%).

CONCLUSION

The timeliness and completeness of routine childhood vaccination in preschool children in this community-based pregnancy cohort is lower than provincial targets. Data on timeliness of vaccination can inform further work on barriers and enablers to vaccination in order to meet provincial targets.

Prevalence and risk of mental disorders in the perinatal period among migrant women: a systematic review and meta-analysis

This study was conducted in order to evaluate the prevalence and risk of mental disorders in the perinatal period among migrant women. Six databases (including MEDLINE) were searched from inception to October 19th, 2015, in addition to citation tracking. Studies were eligible if mental disorders were assessed with validated tools during pregnancy and up to 1 year postpartum among women born outside of the study country. Of 3241 abstracts screened, 53 met the inclusion criteria for the review. Only three studies investigated a mental disorder other than depression. Unadjusted odds ratios were pooled using random effects meta-analysis for elevated depression symptoms during pregnancy (n = 12) and the postpartum (n = 24), stratified by study country due to heterogeneity. Studies from Canada found an increased risk for antenatal (OR = 1.86, 95% CIs 1.32-2.62) and postnatal elevated depression symptoms (OR = 1.98, 95% CIs 1.57-2.49) associated with migrant status. Studies from the USA found a decreased risk of antenatal elevated depression symptoms (OR = 0.71, 95% CIs 0.51-0.99), and studies from the USA and Australia found no association between migrant status and postnatal elevated depression symptoms. Low social support, minority ethnicity, low socioeconomic status, lack of proficiency in host country language and refugee or asylum-seeking status all put migrant populations at increased risk of perinatal mental disorders.

Pregnant Women's Views on the Feasibility and Acceptability of Web-Based Mental Health E-Screening Versus Paper-Based Screening: A Randomized Controlled Trial

BACKGROUND

Major international guidelines recommend mental health screening during the perinatal period. However, substantial barriers to screening have been reported by pregnant and postpartum women and perinatal care providers. E-screening offers benefits that may address implementation challenges.

OBJECTIVE

The primary objective of this randomized controlled trial was to evaluate the feasibility and acceptability of Web-based mental health e-screening compared with paper-based screening among pregnant women. A secondary objective was to identify factors associated with women's preferences for e-screening and disclosure of mental health concerns.

METHODS

Pregnant women recruited from community and hospital-based antenatal clinics and hospital-based prenatal classes were computer-randomized to a fully automated Web-based e-screening intervention group or a paper-based control group. Women were eligible if they spoke or read English, were willing to be randomized to e-screening, and were willing to participate in a follow-up diagnostic interview. The intervention group completed the Antenatal Psychosocial Health Assessment and the Edinburgh Postnatal Depression Scale on a tablet computer, while controls completed them on paper. All women completed self-report baseline questions and were telephoned 1 week after randomization by a blinded research assistant for a MINI International Neuropsychiatric Interview. Renker and Tonkin's tool of feasibility and acceptability of computerized screening was used to assess the feasibility and acceptability of e-screening compared with paper-based screening. Intention-to-treat analysis was used. To identify factors associated with preference for e-screening and disclosure, variables associated with each outcome at P<.20 were simultaneously entered into final multivariable models to estimate adjusted odds ratios (AORs) and 95% CIs.

RESULTS

Of the 675 eligible women approached, 636 agreed to participate (participation rate 94.2%) and were randomized to the intervention (n=305) or control (n=331) groups. There were no significant baseline differences between groups. More women in the e-screening group strongly or somewhat agreed that they would like to use a tablet for answering questions on emotional health (57.9%, 175/302 vs 37.2%, 121/325) and would prefer using a tablet to paper (46.0%, 139/302 vs 29.2%, 95/325), compared with women in the paper-based screening group. There were no differences between groups in women's disclosure of emotional health concerns (94.1%, 284/302 vs 90.2%, 293/325). Women in the e-screening group consistently reported the features of e-screening more favorably than controls (more private or confidential, less impersonal, less time-consuming). In the multivariable models, being in the e-screening group was significantly associated with preferring e-screening (AOR 2.29, 95% CI 1.66-3.17), while no factors were significantly associated with disclosure.

CONCLUSIONS

The findings suggest that mental health e-screening is feasible and acceptable to pregnant women.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01899534; https://clinicaltrials.gov/ct2/show/NCT01899534 (Archived by WebCite at http://www.webcitation.org/6ntWg1yWb).

History of depression and risk of hyperemesis gravidarum: a population-based cohort study

Hyperemesis gravidarum (HG) is a pregnancy condition characterised by debilitating nausea and vomiting. HG has been associated with depression during pregnancy but the direction of the association remains unclear. The aim of this study was to assess whether previous depression is associated with HG. This is a population-based pregnancy cohort study using data from The Norwegian Mother and Child Cohort Study. The study reviewed 731 pregnancies with HG and 81,055 pregnancies without. Logistic regression analyses were performed to examine the association between a lifetime history of depression and hyperemesis gravidarum. Odds ratios were adjusted for symptoms of current depression, maternal age, parity, body mass index, smoking, sex of the child, education and pelvic girdle pain. A lifetime history of depression was associated with higher odds for hyperemesis gravidarum (aOR = 1.49, 95% CI (1.23; 1.79)). Two thirds of women with hyperemesis gravidarum had neither a history of depression nor symptoms of current depression, and 1.2% of women with a history of depression developed HG. A lifetime history of depression increased the risk of HG. However, given the fact that only 1.2% of women with a history of depression developed HG and that the majority of women with HG had no symptoms of depression, depression does not seem to be a main driver in the aetiology of HG.

Protective factors for child development at age 2 in the presence of poor maternal mental health: results from the All Our Babies (AOB) pregnancy cohort

OBJECTIVE

To identify the combination of factors most protective of developmental delay at age 2 among children exposed to poor maternal mental health.

DESIGN

Observational cohort study.

SETTING

Pregnant women were recruited from primary healthcare offices, the public health laboratory service and community posters in Calgary, Alberta, Canada.

PARTICIPANTS

1596 mother-child dyads who participated in the All Our Babies study and who completed a follow-up questionnaire when their child was 2 years old. Among participants who completed the 2-year questionnaire and had complete mental health data (n=1146), 305 women (27%) were classified as high maternal mental health risk.

PRIMARY MEASURES

Child development at age 2 was described and a resilience analysis was performed among a subgroup of families at maternal mental health risk. The primary outcome was child development problems. Protective factors were identified among families at risk, defined as maternal mental health risk, a composite measure created from participants' responses to mental health life course questions and standardised mental health measures.

RESULTS

At age 2, 18% of children were classified as having development problems, 15% with behavioural problems and 13% with delayed social-emotional competencies. Among children living in a family with maternal mental health risk, protective factors against development problems included higher social support, higher optimism, more relationship happiness, less difficulty balancing work and family responsibilities, limiting the child's screen time to <1 hour per day and the child being able to fall asleep in <30 min and sleeping through the night by age 2.

CONCLUSIONS

Among families where the mother has poor mental health, public health and early intervention strategies that support interpersonal relationships, social support, optimism, work-life balance, limiting children's screen time and establishing good sleep habits in the child's first 2 years show promise to positively influence early child development.

Risk and protective factors in early child development: Results from the All Our Babies (AOB) pregnancy cohort

BACKGROUND

Understanding factors that protect against early developmental delay among children who are experiencing adversity can inform prevention and early intervention strategies.

AIMS

To identify risk factors for development delay at one year and protective factors for developmental delay in 'at risk' environments (poor maternal mental health and socio-demographic risk).

METHODS AND PROCEDURES

Data was analyzed from 3360 mother-child dyads who participated in the All Our Babies (AOB) pregnancy cohort. Participants completed four questionnaires spanning pregnancy to one year postpartum and provided access to medical records. Risk factors for developmental delay at age one were identified using bivariate methods and multivariable modeling. Protective factors for child development in 'at risk' family environments were identified using bivariate analyses.

OUTCOMES AND RESULTS

At one year, 17% of children were developmentally delayed, defined as scoring in the monitoring zone on at least 2 of the 5 developmental domains of the Ages and Stages Questionnaire. Prenatal depression, preterm birth, low community engagement, and non-daily parent-child interaction increased the risk of delay. Protective factors for children in 'at risk' environments included relationship happiness, parenting self-efficacy, community engagement, higher social support, and daily parent-child interaction.

CONCLUSIONS AND IMPLICATIONS

The study results suggest that maternal and infant outcomes would be improved, even for vulnerable women, through identification and intervention to address poor mental health and through normalizing engagement with low cost, accessible community resources that can also support parent-child interaction.

Risk of developmental delay: Comparison of late preterm and full term Canadian infants at age 12 months

BACKGROUND

Late preterm (34(0/7) to 36(6/7)weeks gestation) infants may experience developmental delays greater than those found in term (≥ 37(0/7)weeks gestation) infants.

AIM

The aim of this study was to compare the risk of developmental delay between late preterm and full-term Canadian born infants at age 12months, and to determine infant and maternal factors associated with risk of delay.

METHODS

A descriptive comparative study was conducted from data available from the All Our Babies community-based, prospective, pregnancy cohort in Calgary, Alberta. Participants were a sample of mothers of 52 infants born late preterm and 156 randomly selected mothers of term infants, matched for infant sex; eligible infants were singleton births. Mothers completed a developmental screening tool, the Ages and Stages Questionnaire, version 3 (ASQ-3), when their infant was age 12months. Corrected age (CA) was used for preterm infants.

RESULTS

Both late preterm and term infants who required neonatal intensive care (NICU) were more likely to demonstrate risk of developmental delay. Compared to term infants, there was a trend for late preterm infants to be at risk of communication and gross motor delay at age 12months CA that was attenuated to the null when adjustments were made for NICU admission and other covariates.

CONCLUSIONS

Infants born between 34 and 41weeks who are admitted to NICU are at increased risk of developmental delay. Early identification of risk provides an opportunity for referral for developmental assessment and early intervention programming.

Maternal Whole Blood Gene Expression at 18 and 28 Weeks of Gestation Associated with Spontaneous Preterm Birth in Asymptomatic Women

The heterogeneity of spontaneous preterm birth (SPTB) requires an interdisciplinary approach to determine potential predictive risk factors of early delivery. The aim of this study was to investigate maternal whole blood gene expression profiles associated with spontaneous preterm birth (SPTB, <37 weeks) in asymptomatic pregnant women. The study population was a matched subgroup of women (51 SPTBs, 114 term delivery controls) who participated in the All Our Babies community based cohort in Calgary (n = 1878). Maternal blood at 17–23 (sampling time point 1, T₁) and 27–33 weeks of gestation (T₂) were collected. Total RNA was extracted and microarray was performed on 326 samples (165 women). Univariate analyses determined significant clinical factors and differential gene expression associated with SPTB. Thirteen genes were validated using qRT-PCR. Three multivariate logistic models were constructed to identify gene expression at T₁ (Model A), T₂ (Model B), and gene expression fold change from T₁ to T₂ (Model C) associated with SPTB. All models were adjusted for clinical factors. Model C can predict SPTB with 65% sensitivity and 88% specificity in asymptomatic women after adjusting for history of abortion and anaemia (occurring before T₂). Clinical data enhanced the sensitivity of the Models to predict SPTB. In conclusion, clinical factors and whole blood gene expression are associated with SPTB in asymptomatic women. An effective screening tool for SPTB during pregnancy would enable targeted preventive approaches and personalised antenatal care.

Adherence to Canadian physical activity and sedentary behaviour guidelines among children 2 to 13 years of age

Active living is relevant for healthy child development and disease prevention. In 2011-2012 new Canadian Physical Activity and Sedentary Behaviour Guidelines were developed for children under four and 5-17 years of age. This cross-sectional study assessed children's adherence to the national guidelines, using a large sample of Alberta children ages 2-4 and 5-13 years in 2013. The proportions of children achieving the average daily duration of physical activity and screen time recommended were determined, and child and parental predictors of non-achievement were identified. Participants were 631 parent and child dyads. Data were collected by parental reports of physical activity and screen time during weekdays, and analysed using univariate and multivariate techniques (p < 0.05). Logistic regression models were used to examine factors associated with children's non-achievement of physical activity and screen time recommendations while adjusting for covariates. Sixty-two percent of children aged 2-4 and 26% of children aged 5-13 did not meet physical activity time recommendations, and 64% of children aged 2-4 and 23% of children aged 5-13 exceeded the maximum screen time recommendation. Several associations between parental age and education with non-achievement were observed but associations were not consistent across age groups or behaviours. Among preschoolers, those with middle-age parents were more likely to not achieve physical activity recommendations. Evidence of high non-achievement of the recommendations among children 2-4 years highlights the need for increased programming targeting preschool children. Further research is required to identify modifiable risk factors that may inform future health promotion efforts.

Risk and Protective Factors for Late Talking: An Epidemiologic Investigation

OBJECTIVE

To identify risk and protective factors for late talking in toddlers between 24 and 30 months of age in a large community-based cohort.

STUDY DESIGN

A prospective, longitudinal pregnancy cohort of 1023 mother-infant pairs in metropolitan Calgary, Canada, were followed across 5 time points: before 25 weeks gestation, between 34-36 weeks gestation, and at 4, 12, and 24 months postpartum. Toddlers who scored ≤10th percentile on The MacArthur-Bates Communicative Development Inventories: Words and Sentences between 24 and 30 months of age were identified as late talkers. Thirty-four candidate characteristics theoretically and/or empirically linked to language development and/or language impairment were collected using survey methodology.

RESULTS

The prevalence of late talking was 12.6%. Risk factors for late talking in the multivariable model included: male sex (P = .017) and a family history of late talking and/or diagnosed speech or language delay (P = .002). Toddlers were significantly less likely to be late talkers if they engaged in informal play opportunities (P = .013), were read to or shown picture books daily (P < .001), or cared for primarily in child care centers (P = .001).

CONCLUSIONS

Both biological and environmental factors were associated with the development of late talking. Biological factors placed toddlers at risk for late talking, and facets of the environment played a protective role. Enveloping infants and toddlers in language-rich milieus that promote opportunities for playing, reading, and sharing books daily may decrease risk for delayed early vocabulary.

The impact of caesarean section on breastfeeding initiation, duration and difficulties in the first four months postpartum

Background

The caesarean section (c-section) rate in Canada is 27.1 %, well above the 5–15 % of deliveries suggested by the World Health Organization in 2009. Emergency and planned c-sections may adversely affect breastfeeding initiation, milk supply and infant breastfeeding receptivity compared to vaginal deliveries. Our study examined mode of delivery and breastfeeding initiation, duration, and difficulties reported by mothers at 4 months postpartum.

Methods

The All Our Babies study is a prospective pregnancy cohort in Calgary, Alberta, that began in 2008. Participants completed questionnaires at <25 and 34–36 weeks gestation and approximately 4 months postpartum. Demographic, mental health, lifestyle, and health services data were obtained. Women giving birth to singleton infants were included (n = 3021). Breastfeeding rates and difficulties according to mode of birth (vaginal, planned c-section and emergency c-section) were compared using cross-tabulations and chi-square tests. A multivariable logistic regression model was created to examine the association between mode of birth on breastfeeding duration to 12 weeks postpartum.

Results

More women who delivered by planned c-section had no intention to breastfeed or did not initiate breastfeeding (7.4 % and 4.3 % respectively), when compared to women with vaginal births (3.4 % and 1.8 %, respectively) and emergency c-section (2.7 % and 2.5 %, respectively). Women who delivered by emergency c-section were found to have a higher proportion of breastfeeding difficulties (41 %), and used more resources before (67 %) and after (58 %) leaving the hospital, when compared to vaginal delivery (29 %, 40 %, and 52 %, respectively) or planned c-sections (33 %, 49 %, and 41 %, respectively). Women who delivered with a planned c-section were more likely (OR = 1.61; 95 % CI: 1.14, 2.26; p = 0.014) to discontinue breastfeeding before 12 weeks postpartum compared to those who delivered vaginally, controlling for income, education, parity, preterm birth, maternal physical and mental health, ethnicity and breastfeeding difficulties.

Conclusions

We found that when controlling for socio-demographic and labor and delivery characteristics, planned c-section is associated with early breastfeeding cessation. Anticipatory guidance around breastfeeding could be provided to women considering a planned c-section. As well, additional supportive care could be made available to lactating women with emergency c-sections, within the first 24 hours post birth and throughout the early postpartum period.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-0876-1) contains supplementary material, which is available to authorized users.