Birth outcomes associated with prenatal participation in a government support programme for mothers with low incomes

Characteristics of vulnerable women and their association with participation in a Canada Prenatal Nutrition Program site in Toronto, Canada

INTRODUCTION

The Canada Prenatal Nutrition Program (CPNP) supports community organizations to provide maternal-infant health services for socially/economically vulnerable women. As part of our research program exploring opportunities to provide postnatal breastfeeding support through the CPNP, we investigated the sociodemographic and psychosocial characteristics of clients enrolled in a Toronto CPNP site and explored associations with participation.

METHODS

Data were collected retrospectively from the charts of 339 women registered in one southwest Toronto CPNP site from 2013 to 2016. Multivariable regression analyses were used to assess associations between 10 maternal characteristics and three dimensions of prenatal program participation: initiation (gestational age at enrolment in weeks), intensity (number of times one-on-one supports were received) and duration (number of visits).

RESULTS

The mean (SD) age of clients was 31 (5.7) years; 80% were born outside of Canada; 29% were single; and 65% had household incomes below the Statistics Canada family size-adjusted low-income cut-offs. Income was the only characteristic associated with all dimensions of participation. Compared to clients living above the low-income cut-off, those living below the low-income cut-off enrolled in the program 2.85 weeks earlier (95% CI: -5.55 to -0.16), had 1.29 times higher number of one-on-one supports (95% CI: 1.03 to 1.61) and had 1.29 times higher number of program visits (95% CI: 1.02 to 1.63).

CONCLUSION

Our findings show that this CPNP site serves vulnerable women, with few differences in participation based on maternal characteristics. This evidence can guide service provision and monitoring decisions at this program site. Further research is needed to explore new program delivery models to enhance perinatal services for vulnerable women.

Associations Between Sexual Assault and Reproductive and Family Planning Behaviors and Outcomes in Female Veterans

OBJECTIVE

To examine the relationship between lifetime sexual assault (defined as someone having experienced sexual assault in their lifetime) and reproductive health care seeking, contraception usage, and family planning outcomes in female veterans.

METHODS

We conducted a secondary analysis of data collected between 2005 and 2008 from computer-assisted telephone interviews with 1,004 female veterans aged 20-52 years who were enrolled at two Midwestern Department of Veterans Affairs (VA) health care systems. Participants were asked about reproductive, mental, and general health histories, and about lifetime sexual assault. We assessed associations between reproductive histories and contraceptive use among participants who reported lifetime sexual assault, compared with those who had not experienced lifetime sexual assault, by using bivariate and multivariable logistic regression analyses. Lastly, we examined reasons why these participants had not sought Pap test screening.

RESULTS

More than half (62%) of participants reported experiencing lifetime sexual assault. Because there was an association between older age and history of lifetime sexual assault (P<.001), we stratified the analysis by age. Women with a history of lifetime sexual assault were more likely to have had unprotected intercourse for a year or more (adjusted odds ratio [aOR] 2.31, 95% CI 1.35-3.96) and a teen pregnancy (aOR 2.10, 95% CI 1.07-4.12) than women who did not report lifetime sexual assault. When stratified by age, women aged 40-52 years with a history of lifetime sexual assault were more likely to report more than a year of unprotected sex, teen pregnancy, and not seeking prenatal care with their first pregnancy, than women aged 40-52 who did not report lifetime sexual assault. Women who experienced lifetime sexual assault were more likely to report not seeking Pap tests in the past owing to fear and anxiety when compared with women who had not experienced lifetime sexual assault.

CONCLUSION

Female veterans who reported lifetime sexual assault had differences in family planning behaviors compared with women who did not report lifetime sexual assault. These findings have implications for clinicians and VA policymakers when determining family planning and reproductive care delivery needs for female veterans of reproductive age.

A Program Model Describing a Community-Based Mother and Infant Health Program

BACKGROUND AND PURPOSE

The objective of this study was to formulate a MOMS Orange County program model to describe the components and function of a successful community-based maternal and infant health program.

METHODS

A logic framework was used to guide the development of the MOMS program model. Twenty-five MOMS staff members were interviewed; MOMS documents and existing research literature were reviewed. Content analyses were used to identify themes of interviews and the review guide was used to summarize the documents.

RESULTS

The key components of the MOMS program were identified to formulate a narrative and graphic model. The main elements of this model included: target population (underserved women who have low socioeconomic status and have limited access to healthcare in Orange County); theoretical assumptions (social determinants of health, human ecology, self-efficacy); goals (empower women, enhance health of infants, strengthen families); inputs (funded by public and private sources; 50 staff members); activities (care-coordination home visitation community-center group health education); outputs (the number of home visitations, referrals to medical and/or psychological services, and group health education classes); and outcomes (short-term: healthy pregnancy, birth outcomes, family support; medium-term: postpartum well-being, infant development, family functioning; long-term: women's well-being, children's development, family relationships. Future research should test how this model functions to empirically improve maternal, newborn, child, and family health.

IMPLICATIONS FOR PRACTICE

The MOMS program provides a new approach to community-based maternal and infant health interventions focusing on health promotion and disease prevention for underserved families in socioeconomically disadvantaged communities.

Inequities in utilization of prenatal care: a population-based study in the Canadian province of Manitoba

BACKGROUND

Ensuring high quality and equitable maternity services is important to promote positive pregnancy outcomes. Despite a universal health care system, previous research shows neighborhood-level inequities in utilization of prenatal care in Manitoba, Canada. The purpose of this population-based retrospective cohort study was to describe prenatal care utilization among women giving birth in Manitoba, and to determine individual-level factors associated with inadequate prenatal care.

METHODS

We studied women giving birth in Manitoba from 2004/05-2008/09 using data from a repository of de-identified administrative databases at the Manitoba Centre for Health Policy. The proportion of women receiving inadequate prenatal care was calculated using a utilization index. Multivariable logistic regressions were used to identify factors associated with inadequate prenatal care for the population, and for a subset with more detailed risk information.

RESULTS

Overall, 11.5% of women in Manitoba received inadequate, 51.0% intermediate, 33.3% adequate, and 4.1% intensive prenatal care (N = 68,132). Factors associated with inadequate prenatal care in the population-based model (N = 64,166) included northern or rural residence, young maternal age (at current and first birth), lone parent, parity 4 or more, short inter-pregnancy interval, receiving income assistance, and living in a low-income neighborhood. Medical conditions such as multiple birth, hypertensive disorders, antepartum hemorrhage, diabetes, and prenatal psychological distress were associated with lower odds of inadequate prenatal care. In the subset model (N = 55,048), the previous factors remained significant, with additional factors being maternal education less than high school, social isolation, and prenatal smoking, alcohol, and/or illicit drug use.

CONCLUSION

The rate of inadequate prenatal care in Manitoba ranged from 10.5-12.5%, and increased significantly over the study period. Factors associated with inadequate prenatal care included geographic, demographic, socioeconomic, and pregnancy-related factors. Rates of inadequate prenatal care varied across geographic regions, indicating persistent inequities in use of prenatal care. Inadequate prenatal care was associated with several individual indicators of social disadvantage, such as low income, education less than high school, and social isolation. These findings can inform policy makers and program planners about regions and populations most at-risk for inadequate prenatal care and assist with development of initiatives to reduce inequities in utilization of prenatal care.

NAITRE study on the impact of conditional cash transfer on poor pregnancy outcomes in underprivileged women: protocol for a nationwide pragmatic cluster-randomised superiority clinical trial in France

INTRODUCTION

Prenatal care is recommended during pregnancy to improve neonatal and maternal outcomes. Women of lower socioeconomic status (SES) are less compliant to recommended prenatal care and suffer a higher risk of adverse perinatal outcomes. Several attempts to encourage optimal pregnancy follow-up have shown controversial results, particularly in high-income countries. Few studies have assessed financial incentives to encourage prenatal care, and none reported materno-fetal events as the primary outcome. Our study aims to determine whether financial incentives could improve pregnancy outcomes in women with low SES in a high-income country.

METHODS AND ANALYSIS

This pragmatic cluster-randomised clinical trial includes pregnant women with the following criteria: (1) age above 18 years, (2) first pregnancy visit before 26 weeks of gestation and (3) belonging to a socioeconomically disadvantaged group. The intervention consists in offering financial incentives conditional on attending scheduled pregnancy follow-up consultations. Clusters are 2-month periods with random turnover across centres. A composite outcome of maternal and neonatal morbidity and mortality is the primary endpoint. Secondary endpoints include maternal or neonatal outcomes assessed separately, qualitative assessment of the perception of the intervention and cost-effectiveness analysis for which children will be followed to the end of their first year through the French health insurance database. The study started in June 2016, and based on an expected decrease in the primary endpoint from 18% to 14% in the intervention group, we plan to include 2000 women in each group.

ETHICS AND DISSEMINATION

Ethics approval was first gained on 28 September 2014. An independent data security and monitoring committee has been established. Results of the main trial and each of the secondary analyses will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT02402855; pre-results.

Incentives for increasing prenatal care use by women in order to improve maternal and neonatal outcomes

BACKGROUND

Prenatal care is recommended during pregnancy as a method to improve neonatal and maternal outcomes. Improving the use of prenatal care is important, particularly for women at moderate to high risk of adverse outcomes. Incentives are sometimes utilized to encourage women to attend prenatal care visits.

OBJECTIVES

To determine whether incentives are an effective tool to increase utilization of timely prenatal care among women.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015) and the reference lists of all retrieved studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs), quasi-RCTs, and cluster-RCTs that utilized direct incentives to pregnant women explicitly linked to initiation and frequency of prenatal care were included. Incentives could include cash, vouchers, coupons or products not generally offered to women as a standard of prenatal care. Comparisons were to no incentives and to incentives not linked directly to utilization of care. We also planned to compare different types of interventions, i.e. monetary versus products or services.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and methodological quality. Two review authors independently extracted data. Data were checked for accuracy.

MAIN RESULTS

We identified 11 studies (19 reports), six of which we excluded. Five studies, involving 11,935 pregnancies were included, but only 1893 pregnancies contributed data regarding our specified outcomes. Incentives in the studies included cash, gift card, baby carrier, baby blanket or taxicab voucher and were compared with no incentives. Meta-analysis was performed for only one outcome 'Return for postpartum care' and this outcome was not pre-specified in our protocol. Other analyses were restricted to data from single studies.Trials were at a moderate risk of bias overall. Randomization and allocation were adequate and risk of selection bias was low in three studies and unclear in two studies. None of the studies were blinded to the participants. Blinding of outcome assessors was adequate in one study, but was limited or not described in the remaining four studies. Risk of attrition was deemed to be low in all studies that contributed data to the review. Two of the studies reported or analyzed data in a manner that was not consistent with the predetermined protocol and thus were deemed to be at high risk. The other three studies were low risk for reporting bias. The largest two of the five studies comprising the majority of participants took place in rural, low-income, homogenously Hispanic communities in Central America. This setting introduces a number of confounding factors that may affect generalizability of these findings to ethnically and economically diverse urban communities in developed countries.The five included studies of incentive programs did not report any of this review's primary outcomes: preterm birth, small-for-gestational age, or perinatal death.In terms of this review's secondary outcomes, pregnant women receiving incentives were no more likely to initiate prenatal care (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.78 to 1.38, one study, 104 pregnancies). Pregnant women receiving incentives were more likely to attend prenatal visits on a frequent basis (RR 1.18, 95% CI 1.01 to 1.38, one study, 606 pregnancies) and obtain adequate prenatal care defined by number of "procedures" such as testing blood sugar or blood pressure, vaccinations and counseling about breastfeeding and birth control (mean difference (MD) 5.84, 95% CI 1.88 to 9.80, one study, 892 pregnancies). In contrast, women who received incentives were more likely to deliver by cesarean section (RR 1.97, 95% CI 1.18 to 3.30, one study, 979 pregnancies) compared to those women who did not receive incentives.Women who received incentives were no more likely to return for postpartum care based on results of meta-analysis (average RR 0.75, 95% CI 0.21 to 2.64, two studies, 833 pregnancies, Tau² = 0.81, I² = 98%). However, there was substantial heterogeneity in this analysis so a subgroup analysis was performed and this identified a clear difference between subgroups based on the type of incentive being offered. In one study, women receiving non-cash incentives were more likely to return for postpartum care (RR 1.26, 95% CI 1.09 to 1.47, 240 pregnancies) than women who did not receive non-cash incentives. In another study, women receiving cash incentives were less likely to return for postpartum care (RR 0.43, 95% CI 0.30 to 0.62, 593 pregnancies) than women who did not receive cash incentives.No data were identified for the following secondary outcomes: frequency of prenatal care; pre-eclampsia; satisfaction with birth experience; maternal mortality; low birthweight (less than 2500 g); infant macrosomia (birthweight greater than 4000 g); or five-minute Apgar less than seven.

AUTHORS' CONCLUSIONS

The included studies did not report on this review's main outcomes: preterm birth, small-for-gestational age, or perinatal death. There is limited evidence that incentives may increase utilization and quality of prenatal care, but may also increase cesarean rate. Overall, there is insufficient evidence to fully evaluate the impact of incentives on prenatal care initiation. There are conflicting data as to the impact of incentives on return for postpartum care. Two of the five studies which accounted for the majority of women in this review were conducted in rural, low-income, overwhelmingly Hispanic communities in Central America, thus limiting the external validity of these results.There is a need for high-quality RCTs to determine whether incentive program increase prenatal care use and improve maternal and neonatal outcomes. Incentive programs, in particular cash-based programs, as suggested in this review and in several observational studies may improve the frequency and ensure adequate quality of prenatal care. No peer-reviewed data have been made publicly available for one of the largest incentive-based prenatal programs - the statewide Medicaid-based programs within the United States. These observational data represent an important starting point for future research with significant implications for policy development and allocation of healthcare resources. The disparate findings related to attending postpartum care should also be further explored as the findings were limited by the number of studies. Future large RCTs are needed to focus on the outcomes of preterm birth, small-for-gestational age and perinatal outcomes.

Increased risk for postpartum psychiatric disorders among women with past pregnancy loss

BACKGROUND

Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.

METHODS

One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

RESULTS

Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

CONCLUSIONS

Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

In an idealized world: can discrepancies across self-reported parental care and high betrayal trauma during childhood predict infant attachment avoidance in the next generation?

Adult caregivers' idealization of their parents as assessed by the Adult Attachment Interview is a risk factor for the intergenerational transmission of the insecure-avoidant attachment style. This study evaluated a briefer screening approach for identifying parental idealization, testing the utility of prenatal maternal self-report measures of recalled betrayal trauma and parental care in childhood to predict observationally assessed infant attachment avoidance with 58 mother-infant dyads 18 months postpartum. In a logistic regression that controlled for maternal demographics, prenatal psychopathology, and postnatal sensitivity, the interaction between women's self-reported childhood high betrayal trauma and the level of care provided to them by their parents was the only significant predictor of 18-month infant security versus avoidance. Results suggest that betrayal trauma and recalled parental care in childhood can provide a means of identifying caregivers whose infant children are at risk for avoidant attachment, potentially providing an efficient means for scientific studies and clinical intervention aimed at preventing the intergenerational transmission of attachment problems.

The relationship between the built environment and birthweight

A growing body of research has broadened the study of the relationship between the built environment and health from individual housing conditions, to include the larger neighborhood environment and its subsequent effects on the health outcomes of its residents. Research has connected measures of neighborhood quality to changes in health outcomes for residents, yet little work has been done to develop measures that capture and quantify the physical features of the neighborhood's manmade surroundings, also known as the built environment. This paper investigates the current literature detailing the relationship between the built environment and low birthweight and suggests potential interventions. Interventions developed at the county, neighborhood, and individual levels could aid community leaders and policymakers in breaking the cycle of low birthweight.