Late pregnancy abortions: an analysis of Québec stillbirth data, 1981–2006

Later Gestational Age Abortion in Canada: A Scoping Review

Since the decriminalization of abortion in Canada in 1988, there have been no legal restrictions on when in pregnancy an abortion can take place. However, abortion care is only consistently available in Canada up to 23 weeks and 6 days; women, transgender men, and gender non-binary individuals who need abortion care after 24 weeks typically obtain services in the United States. Furthermore, abortion care beyond 16 weeks is unavailable in some regions of the country. The authors undertook this scoping review to explore what is currently known about later gestational age abortion in Canada. Using a six-stage framework, they identified 32 relevant sources that were published in the last 30 years, and they consulted with seven topic experts to validate the findings from our document synthesis. The limited body of literature on abortion after 16 weeks in Canada sheds light on the safety of both medical and instrumentation procedures, the type and training of abortion-providing clinicians, the characteristics of those obtaining abortion care after the first trimester, and geographic disparities in service availability. These topic experts emphasized the need for future research on patient experiences and developing and implementing strategies to help provinces and territories expand abortion care to later gestational ages and improve comprehensive reproductive health services.

Stillbirth in Canada: anachronistic definition and registration processes impede public health surveillance and clinical care

The archaic definition and registration processes for stillbirth currently prevalent in Canada impede both clinical care and public health. The situation is fraught because of definitional problems related to the inclusion of induced abortions at ≥20 weeks’ gestation as stillbirths: widespread uptake of prenatal diagnosis and induced abortion for serious congenital anomalies has resulted in an artefactual temporal increase in stillbirth rates in Canada and placed the country in an unfavourable position in international (stillbirth) rankings. Other problems with the Canadian stillbirth definition and registration processes extend to the inclusion of fetal reductions (for multi-fetal pregnancy) as stillbirths, and the use of inconsistent viability criteria for reporting stillbirth. This paper reviews the history of stillbirth registration in Canada, provides a rationale for updating the definition of fetal death and recommends a new definition and improved processes for fetal death registration. The recommendations proposed are intended to serve as a starting point for reformulating issues related to stillbirth, with the hope that building a consensus regarding a definition and registration procedures will facilitate clinical care and public health.

Stillbirth Among Arab Women in Canada, 1981-2015

OBJECTIVES

The Arabic-speaking population is increasing in Europe and North America. Evidence suggests that Arab migrants have a greater risk of adverse birth outcomes than nonmigrants, but the risk of stillbirth is largely understudied. We examined inequality in stillbirth rates between Arab women and the French and English majority of women in Quebec, Canada.

METHODS

We conducted a retrospective study of all births in Quebec from 1981 through 2015. We computed stillbirth rates by period and cause of death, and we used log binomial regression to estimate the association between Arabic mother tongue and stillbirth, adjusted for maternal characteristics.

RESULTS

Stillbirth rates per 1000 births overall were lower among women with Arabic mother tongue (3.89) than among women with French or English mother tongue (4.52), and rates changed little over time. However, Arabic-speaking women from Arab countries had a higher adjusted risk of stillbirth than French- or English-speaking women (risk ratio = 1.23; 95% confidence interval, 1.07-1.42). Congenital anomalies, termination of pregnancy, and undetermined causes contributed to a disproportionate number of stillbirths among women with Arabic mother tongue compared with the French- and English-speaking majority.

CONCLUSIONS

Arabic-speaking women from Arab countries have higher risks of stillbirth compared with the French and English majority in Quebec. Strategies to reduce stillbirth risk among Arabic speakers should focus on improving identification of causes of death.

Cross-cultural perspectives on decision making regarding noninvasive prenatal testing: A comparative study of Lebanon and Quebec

Noninvasive prenatal testing (NIPT), based on the detection of cell-free fetal DNA in maternal blood, has transformed the landscape of prenatal care by offering clinical benefits (noninvasive, high specificity and sensitivity, early detection of abnormalities) compared to existing prenatal screening tests. NIPT has expanded rapidly and is currently commercially available in most of the world. As NIPT spreads globally, culturally sensitive and ethically sound implementation will require policies that take into consideration the social and cultural context of prenatal testing decisions. In a Western context, the main ethical argument for providing access and public funding of prenatal tests is the promotion of reproductive autonomy (also referred to as "procreative liberty" and "reproductive freedom"), by enabling pregnant women and couples to access information about the fetus in order to choose a certain course of action for pregnancy management (continuation of pregnancy and preparation for birth or termination). So how is the framework of reproductive autonomy operationalized in non-Western cultural contexts? We used Quebec, Canada, and Beirut, Lebanon, for case studies to explore what ethical considerations related to reproductive autonomy should guide the implementation of the test in various cultural contexts. To answer this question, we conducted a qualitative study to (1) explore the perceptions, values, and preferences of pregnant women and their partners about NIPT and (2) examine how these values and perceptions influence reproductive autonomy and decision making in relation to NIPT in these two different cultural settings, Lebanon and Quebec. Our findings may guide health care professionals in providing counseling and in helping women and their partners make better informed prenatal testing decisions. Further, at a policy level, such understanding might inform the development of local guidelines and policies that are appropriate to each context.

Bariatric surgery and the risk of congenital anomalies in subsequent pregnancies

BACKGROUND

Data on the relationship between bariatric surgery and risk of birth defects are conflicting.

OBJECTIVES

We studied the association of bariatric surgery with birth defects in future pregnancies in a large cohort of women.

METHODS

We carried out a retrospective cohort study of 2,194,348 pregnancies that occurred between 1989 and 2016 in Quebec, Canada. We identified women who had bariatric surgery before pregnancy, and included nonobese women with no surgery as a comparison group. We estimated risk ratios (RRs) and 95% CIs for the associations between bariatric surgery and the risk of birth defects, using log-binomial regression models adjusted for maternal age, comorbidities, parity, whether there was a multiple birth, socioeconomic deprivation, and the presence of folic acid food fortification.

RESULTS

In this study, 1845 deliveries were among women who had bariatric surgery before pregnancy (0.08%). Having bariatric surgery was associated with 1.20 times the risk of birth defects in later pregnancies (95% CI: 1.01, 1.43), compared with having no surgery or obesity. Obesity without having bariatric surgery was, in contrast, more weakly associated with birth defects (RR: 1.09; 95% CI: 1.07, 1.12). The association with bariatric surgery was greater for heart (RR: 1.47; 95% CI: 1.02, 2.12) and musculoskeletal defects (RR: 1.32; 95% CI: 1.02, 1.71). Associations were primarily present before folic acid food fortification was implemented (RR: 2.03; 95% CI: 1.41, 2.92), but not after (RR: 1.05; 95% CI: 0.86, 1.28).

CONCLUSIONS

Having bariatric surgery was a risk factor for birth defects, and particularly heart and musculoskeletal defects. After fortification, however, an association was no longer present. Future studies are needed to determine whether micronutrient supplementation underpins the difference in the changing results pre- and postfortification.

Decreasing use of autopsy for stillbirths and infant deaths: missed opportunity

OBJECTIVE

We assessed whether the tendency towards decreasing use of fetal and infant autopsy was associated with a greater proportion of deaths in which the cause is never found.

STUDY DESIGN

We computed autopsy rates over time for 13,466 stillbirths and 16,880 infant deaths in Quebec, Canada, 1981-2015. We assessed the proportion of deaths with an undetermined cause and determined the relationship with non-autopsy over time.

RESULT

Autopsy rates declined by 29% for stillbirths and 36% for infant deaths during the study. The proportion of non-autopsied cases with an undetermined cause of death increased only for stillbirths, however. Among non-autopsied stillbirths, the risk of having an undetermined cause of death was 1.64 times higher in 2005-2015 compared with 1981-1992 (95% confidence interval 1.25, 2.15).

CONCLUSION

Greater use of autopsy has potential to minimize the number of stillbirths with an undetermined cause of death, and may be helpful for prevention.

Abortion and Infant Mortality on the First Day of Life

BACKGROUND

Fetal imaging for congenital anomalies increases pregnancy terminations late in gestation.

OBJECTIVES

We assessed whether late-pregnancy terminations can accidentally result in live births, and how these births impact infant mortality rates over time.

METHODS

We carried out a population-level analysis of 12,141 infant deaths in Quebec, Canada from 1986 to 2012. We calculated the proportion of infants born alive who died following pregnancy termination. The exposure was pregnancy termination with or without congenital anomaly recorded on death certificates. The main outcome was mortality on the first day of life by the hour.

RESULTS

Pregnancy termination was the cause of 19.4 infant deaths per 100,000 in 2000-2012, compared with 1.0 per 100,000 in 1986-1999. Most deaths after termination occurred in the first 3 h of life among infants with anomalies who weighed <500 g. In 2000-2012, infants who died following pregnancy termination led to an excess of 0.2 deaths per 1,000 on the first day of life, i.e. an 8.6% increase in the infant mortality rate (p value = 0.002).

CONCLUSIONS

Pregnancy termination in mid-gestation carries the risk of accidental live birth. These neonates increasingly affect infant mortality rates. Better recording is needed, including data on the prevention and management of accidental live births after pregnancy termination.

Stillbirth in an Anglophone minority of Canada

OBJECTIVES

We assessed trends in stillbirth over time for Francophones and Anglophones of Quebec, a large Canadian province with publically funded health care and an English-speaking minority.

METHODS

We calculated stillbirth rates for Francophones and Anglophones, and estimated hazard ratios (HR) by decade from 1981 to 2010, adjusting for maternal characteristics. We analyzed temporal trends by gestational interval and cause of fetal death.

RESULTS

Stillbirth rates decreased in Quebec during the three decades, due to improved rates in Francophones. Rates decreased for Anglophones in 1991-2000, but increased in 2001-2010 at term, during the second trimester, and for most causes of fetal death. In the 2000s, the hazard of stillbirth for Anglophones was nearly the same as the hazard for Francophones in the 1980s (HR 0.93, 95 % confidence interval 0.82, 1.05).

CONCLUSIONS

Stillbirth rates declined in both Francophones and Anglophones before the turn of the century, but increased thereafter for Anglophones, suggesting that linguistic inequalities in stillbirth may be emerging in Quebec. Linguistic status may be a useful marker for surveillance of inequalities in stillbirth.

Educational inequality in stillbirth: temporal trends in Québec from 1981 to 2009

OBJECTIVE

Educational inequality in stillbirth has been documented in high-income countries and the province of Québec, Canada, but temporal trends are poorly understood. Our objective was to determine time trends in inequality related to maternal education for all-cause and cause-specific stillbirth over the past three decades in Québec.

METHODS

We included 2,397,971 live births and 9,983 stillbirths from 1981 through 2009 using Québec vital statistics. For each decade, we computed measures of inequality capturing relative (relative index of inequality, RII) and absolute (slope index of inequality, SII) differences between the least- and most-educated mothers for all-cause and cause-specific stillbirth, adjusting for maternal characteristics.

RESULTS

Stillbirth rates decreased over time for all education levels. Absolute educational inequality (SII 2.5 per 1000 births, 95% CI 2.1-2.8; all periods combined) was stable over time, whereas relative inequality increased (RII(1981-1989) 1.8 vs. RII(2000-2009) 2.3). Absolute inequality decreased for stillbirths caused by placental abruption (SII(1981-1989) 0.6 vs. SII(2000-2009) 0.3), but increased for unspecified causes (SII(1981-1989) 0.2 vs. SII(2000-2009) 0.7).

CONCLUSIONS

Absolute educational inequality in stillbirth persisted and relative inequality increased over the past three decades, despite an overall decrease in stillbirth rates. The decrease in absolute inequality for placental abruption was countered by an increase for unspecified causes. A better understanding of the underlying components of unspecified causes is needed to further address educational inequality in stillbirth.

Francophone and Anglophone perinatal health: temporal and regional inequalities in a Canadian setting, 1981-2008

OBJECTIVES

We evaluated temporal and regional inequalities in adverse birth outcomes between Anglophones and Francophones of a Canadian province.

METHODS

Odds ratios and rate differences in preterm birth (PTB, <37 gestational weeks) and small-for-gestational-age (SGA) birth were computed for Anglophones relative to Francophones for singleton live births in Québec from 1981 to 2008 (N = 2,292,237), adjusting for maternal characteristics. Trends over time and residential region were evaluated.

RESULTS

Rates of PTB and SGA birth overall were lower for Anglophones relative to Francophones, but temporal and regional trends varied by outcome. Although PTB rates increased over time, inequalities between Francophones and Anglophones were relatively stable. In contrast, inequalities in SGA birth narrowed over time as Francophone rates declined more than Anglophones. Inequalities in SGA birth favored Anglophones overall, but the gap gradually reversed in Montréal (the largest metropolitan center) to currently favor Francophones.

CONCLUSIONS

PTB and SGA birth rates favored Anglophones over Francophones. The linguistic gap was generally stable over time for PTB, but narrowed or reversed for SGA birth. Language may be used to capture inequalities in perinatal health in countries where different linguistic groups predominate.