The Ontario Mother and Infant Study (TOMIS) III: a multi-site cohort study of the impact of delivery method on health, service use, and costs of care in the first postpartum year

Canadian Women's Experience of Postnatal Care: A Mixed Method Study

Background

The postnatal period remains unstandardized in terms of care and postnatal visits with a dearth of information on the experience from Canadian women.

Purpose

To explore (1) with whom and how often women receive postnatal follow-up visits and (2) the postnatal care experiences of Canadian mothers.

Methods

Using a cross-sectional design, women who had given birth within the past 6 months were recruited to complete an online survey. Frequencies were computed for quantitative outcomes and thematic analysis was used for qualitative responses.

Results

A total of 561 mothers completed the survey. Women saw on average 1.9 different postnatal healthcare providers, primarily family doctors (72.4%). 3.2% had no postnatal visits and 37.6% had 4  or more within 6 weeks. 76.1% women were satisfied with their postnatal care. Women's satisfactory care in the postnatal period was associated with in-person and at home follow-ups, receiving support, and receiving timely, appropriate care for self and newborn. Unsatisfactory care was associated with challenges accessing care, experiencing gaps in follow-up visits, and having unsatisfactory assessment for their own recovery.

Conclusion

There is considerable variation in the timing and frequency of postnatal visits. While many women are experiencing satisfactory care, women are still reporting dissatisfaction and are facing challenges.

Enhancing research publications and advancing scientific writing in health research collaborations: sharing lessons learnt from the trenches

BACKGROUND

Disseminating research protocols, processes, methods or findings via peer-reviewed publications has substantive merits and benefits to various stakeholders.

PURPOSE

In this article, we share strategies to enhance research publication contents (ie, what to write about) and to facilitate scientific writing (ie, how to write) in health research collaborations.

METHODS

Empirical experience sharing.

RESULTS

To enhance research publication contents, we encourage identifying appropriate opportunities for publications, publishing protocols ahead of results papers, seeking publications related to methodological issues, considering justified secondary analyses, and sharing academic process or experience. To advance writing, we suggest setting up scientific writing as a goal, seeking an appropriate mentorship, making full use of scientific meetings and presentations, taking some necessary formal training in areas such as effective communication and time and stress management, and embracing the iterative process of writing.

CONCLUSION

All the strategies we share are dependent upon each other; and they advocate gradual academic accomplishments through study and training in a "success-breeds-success" way. It is expected that the foregoing shared strategies in this paper, together with other previous guidance articles, can assist one with enhancing research publications, and eventually one's academic success in health research collaborations.

Predictors of Postpartum Depression Among Immigrant Women in the Year After Childbirth

BACKGROUND

Immigrant women are at increased risk for postpartum depression (PPD). The factors that influence PPD among immigrant women are poorly understood. The purpose of this study was to identify individual- and community-level factors predictive of PPD among immigrant women living in a large Ontario city at 6 weeks, 6 months, and 1 year postpartum.

METHODS

The study involved a secondary analysis of a prospective cohort study, The Ontario Mother and Infant Study 3. This study included 519 immigrant women who were recruited from two hospitals in one urban city and delivered full-term singleton infants. Women completed a written questionnaire in hospital, followed by structured telephone interviews at 6 weeks, 6 months, and 1 year after hospital discharge. Generalized estimating equations were used to explore factors associated with PPD, measured using the Edinburgh Postnatal Depression Scale (EPDS) and two thresholds for depression (≥12 and ≥9).

RESULTS

Rates of PPD at all time points were 8%-10% for EPDS scores of ≥12. For EPDS scores of ≥9, rates of PPD more than doubled at all time points. A lack of social support was strongly associated with PPD in all analyses. Living in Canada for ≤2 years, poor perceptions of health, and lower mental health functioning were other important predictors of PPD. Living in communities with a high prevalence of immigrants and low income also was associated with PPD.

CONCLUSIONS

Complex individual and community-level factors are associated with PPD in immigrant women. Understanding these contextual factors can inform a multifaceted approach to addressing PPD.

Comparing the feasibility, acceptability, clinical-, and cost-effectiveness of mental health e-screening to paper-based screening on the detection of depression, anxiety, and psychosocial risk in pregnant women: a study protocol of a randomized, parallel-group, superiority trial

BACKGROUND

Stress, depression, and anxiety affect 15% to 25% of pregnant women. However, substantial barriers to psychosocial assessment exist, resulting in less than 20% of prenatal care providers assessing and treating mental health problems. Moreover, pregnant women are often reluctant to disclose their mental health concerns to a healthcare provider. Identifying screening and assessment tools and procedures that are acceptable to both women and service providers, cost-effective, and clinically useful is needed.

METHODS/DESIGN

The primary objective of this randomized, parallel-group, superiority trial is to evaluate the feasibility and acceptability of a computer tablet-based prenatal psychosocial assessment (e-screening) compared to paper-based screening. Secondary objectives are to compare the two modes of screening on: (1) the level of detection of prenatal depression and anxiety symptoms and psychosocial risk; (2) the level of disclosure of symptoms; (3) the factors associated with feasibility, acceptability, and disclosure; (4) the psychometric properties of the e-version of the assessment tools; and (5) cost-effectiveness. A sample of 542 women will be recruited from large, primary care maternity clinics and a high-risk antenatal unit in an urban Canadian city. Pregnant women are eligible to participate if they: (1) receive care at one of the recruitment sites; (2) are able to speak/read English; (3) are willing to be randomized to e-screening; and (4) are willing to participate in a follow-up diagnostic interview within 1 week of recruitment. Allocation is by computer-generated randomization. Women in the intervention group will complete an online psychosocial assessment on a computer tablet, while those in the control group will complete the same assessment in paper-based form. All women will complete baseline questionnaires at the time of recruitment and will participate in a diagnostic interview within 1 week of recruitment. Research assistants conducting diagnostic interviews and physicians will be blinded. A qualitative descriptive study involving healthcare providers from the recruitment sites and women will provide data on feasibility and acceptability of the intervention. We hypothesize that mental health e-screening in primary care maternity settings and high-risk antenatal units will be as or more feasible, acceptable, and capable of detecting depression, anxiety, and psychosocial risk compared to paper-based screening.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01899534.

An inventory of Canadian pregnancy and birth cohort studies: research in progress

Background

A web-based inventory was developed as a voluntary registry of Canadian pregnancy and birth cohort studies, with the objective to foster collaboration and sharing of research tools among cohort study groups as a means to enrich research in maternal and child health across Canada.

Description

Information on existing birth cohort studies conducted in Canada exclusively or as part of broader international initiatives was accessed by searching the literature in PubMed and PsychInfo databases. Additional studies were identified by enquiring about the research activities of researchers at Canadian universities or working in affiliated hospitals or research centres or institutes. Of the fifty-eight birth cohort studies initially identified, forty-six were incorporated into the inventory if they were of a retrospective and/or prospective longitudinal design and with a minimum of two phases of data collection, with the first period having occurred before, during, or shortly after pregnancy and had an initial study sample size of a minimum of 200 participants.

Information collected from each study was organized into four main categories: basic information, data source and period of collection, exposures, and outcome measures and was coded and entered into an Excel spreadsheet. The information incorporated into the Excel spreadsheet was double checked, completed when necessary, and verified for completeness and accuracy by contacting the principal investigator or research coordinator. All data collected were then uploaded onto the website of the Institute of Human Development Child and Youth Health of the Canadian Institutes of Health Research. Subsequently, the database was updated and developed as an online searchable inventory on the website of the Maternal, Infant, Child and Youth Research Network.

Conclusions

This inventory is unique, as it represents detailed information assembled for the first time on a large number of Canadian birth cohort studies. Such information provides a valuable resource for investigators in the planning stages of cohort studies and identifying current research gaps.

The effect of delivery method on breastfeeding initiation from the The Ontario Mother and Infant Study (TOMIS) III

OBJECTIVE

To report on the relationship between delivery method (cesarean vs. vaginal) and type (planned vs. unplanned) and breastfeeding initiation in hospital and continuation to 6 weeks postpartum as self-reported by study participants.

DESIGN

Quantitative sequential mixed methods design.

SETTING

Women were recruited from 11 hospital sites in Ontario, Canada.

PARTICIPANTS

Participants included 2,560 women age 16 years or older who delivered live, full-term, singleton infants.

METHODS

Data were collected from an in-hospital questionnaire, hospital records, and a 6-week postpartum interview.

RESULTS

Ninety-two percent of women reported initiating breastfeeding, and 74% continued to 6 weeks. The method of delivery, when defined as cesarean versus vaginal, was not a determining factor in breastfeeding initiation in hospital or in the early postdischarge period. An unexpected delivery method (i.e., unplanned cesarean or instrument-assisted vaginal deliveries) was associated, at a statistically significant level, with an increased likelihood of initiating breastfeeding and continuation to 6 weeks postdischarge.

CONCLUSION

Breastfeeding can be considered a coping strategy that serves to normalize an abnormal experience and allows the individual to once again assume control. These unexpected results warrant further investigation to understand why women make the decision to initiate breastfeeding, why they choose to continue breastfeeding, and how they can be supported to achieve exclusive breastfeeding as recommended for infants in the first 6 months.

Influence of maternal birthplace on postpartum health and health services use

This study examined differences in health status, rates of postpartum depression, perceptions of health services, unmet service needs, and barriers to service use among women born in and outside of Canada at 6 weeks following postpartum discharge from hospital. A secondary analysis of data gathered for a longitudinal cross-sectional survey of postpartum health and service use was conducted. Data from participants recruited from two urban hospitals were used for this analysis (n = 1,045). Analyses examined differences between women born in and outside of Canada. Immigrant women were significantly more likely to experience fair/poor postpartum health status and risk for postpartum depression. Immigrant women were also more likely to rate community health services as fair/poor, and were less likely to be able to get care for emotional health problems. Postpartum health services need to be responsive and accessible in order to meet the needs of immigrant women.

Hidden costs associated with the universal application of risk management in maternity care

This paper presents a critical analysis of risk management in maternity care and the hidden costs associated with the practice in healthy women. Issues of quality and safety are driving an increased emphasis by health services on risk management in maternity care. Medical risk in pregnancy is known to benefit 15% or less of all pregnancies. Risk management applied to the remaining 85% of healthy women results in the management of risk in the absence of risk. The health cost to mothers and babies and the economic burden on the overall health system of serious morbidity has been omitted from calculations comparing costs of uncomplicated caesarean birth and uncomplicated vaginal birth. The understanding that elective caesarean birth is cost-neutral when compared to a normal vaginal birth has misled practitioners and contributed to over use of the practice. For the purpose of informing the direction of maternity service policy it is necessary to expose the effect the overuse of medical intervention has on the overall capacity of the healthcare system to absorb the increasing demand for operating theatre resources in the absence of clinical need.

Understanding rising caesarean section trends: relevance of inductions and prelabour obstetric interventions at term

AIMS

Single center 10-years audit on the relation between labour ward management and caesarean section rate, with special emphasis on the impact of reduced induction rate and the use of strict criteria for the diagnosis of onset of spontaneous labour and the indication for induction of labour.

METHODS

Retrospective classification of all deliveries between 1st January 2001 and 31st December 2010 in Ziekenhuis Oost Limburg, Genk Belgium, into the 10- group classification according to Robson. Numbers and rate of caesarean sections were defined for primiparous and multiparous women in spontaneous labour (groups 1 and 3 respectively), after induced labour (groups 2 and 4 respectively), with caesarean scar uterus (group 5) or with other gestational complications (groups 6 to 10). For these groups, a 10-years evolution was evaluated.

RESULTS

In a total of 19.675 deliveries, the overall caesarean section rate increased from 20% (380/1937) in 2001 to 25% (534/2121) in 2007 (p < 0.001), and decreased again to 20% in 2010 (415/2068) (p < 0.001). The increase of caesarean sections before 2007 was associated with an increase of inductions in singleton cephalic pregnancies at term from 28.5% (410/1437) in 2003 to 35.9% (551/1536) in 2006 (p < 0.001). The decrease of caesarean sections after 2007 occurred both in induced labours, as a direct consequence of rationalised reduction of induction rate, and in spontaneous labours, following introduction of strict criteria for diagnosis of labour. Despite a similar caesarean section rate of 20% in 2001 and 2010, the 6.6% (136/2068) repeat caesarean section rate in 2010 was higher than 4.2% (81/1937) in 2001 (p = 0.001).

CONCLUSION

This single centre audit illustrates that increased induction rate is associated with increased caesarean section rate. This evolution can be reverted through a rationalised management aiming for reduction of induced labours and improved diagnosis of labour.