Retaining women in a prenatal care randomized controlled trial in Canada: implications for program planning

Clinically Integrated Breastfeeding Peer Counseling to Promote Breastfeeding Equity

OBJECTIVE

This study aimed to determine whether clinically integrated Breastfeeding Peer Counseling (ci-BPC) added to usual lactation care reduces disparities in breastfeeding intensity and duration for Black and Hispanic/Latine participants.

STUDY DESIGN

This study is a pragmatic, randomized control trial (RCT) of ci-BPC care at two ci-BPC-naïve obstetrical hospital facilities in the greater Chicago area. Participants will include 720 patients delivering at Hospital Site 1 and Hospital Site 2 who will be recruited from eight prenatal care sites during midpregnancy. Participants must be English or Spanish speaking, planning to parent their child, and have no exposure to ci-BPC care prior to enrollment. Randomization will be stratified by race and ethnicity to create three analytic groups: Black, Hispanic/Latine, and other races.

RESULTS

The primary outcome will be breastfeeding duration. Additional outcomes will include the proportion of breastmilk feeds during the delivery admission, at 6-week postdelivery, and at 6-month postdelivery. A process evaluation will be conducted to understand implementation outcomes, facilitators, and barriers to inform replication and scaling of the innovative ci-BPC model.

CONCLUSION

This research will produce findings of relevance to perinatal patients and their families, the vast majority of whom desire to provide breastmilk to their infants and require support to succeed with their feeding goals. As the largest RCT of ci-BPC in the United States to date, this research will improve the quality of evidence available regarding the effectiveness of ci-BPC at reducing disparities. These findings will help patients and stakeholders determine the benefits of accepting and adopting the program and inform policies focused on improving perinatal care and reducing maternal/child health disparities. This study is registered with Clinical Trial (identifier: NCT05441709).

KEY POINTS

· Ci-BPC can promote racial breastfeeding equity.. · Ci-BPC has not been tested as a generalized lactation strategy in prior trials and is underused.. · This RCT will identify if ci-BPC can reduce breastfeeding disparities for Black and Hispanic patients..

Pathways from Maternal Adverse Childhood Experiences to Substance Use in Pregnancy: Findings from the All Our Families Cohort

Background: Exposure to adverse childhood experiences (ACEs) is a risk factor for maternal substance use in pregnancy, however, mechanisms by which maternal ACEs may influence substance use in pregnancy have not been fully explored. The current study examines the association between maternal ACEs and substance use in pregnancy (i.e., alcohol, smoking, and drug use) and explores mediating pathways. Methods: A community sample of 1,994 women as part of the All Our Families Cohort were recruited in pregnancy in Calgary, Canada, between 2008 and 2011. Women provided retrospective reports of ACE exposure before age 18 as well as reports of demographic information, substance use (i.e., moderate-to-high alcohol use, any smoking, or any drug use), a previous history of substance use difficulties, and depressive symptoms during pregnancy. Path analyses were used to examine maternal income, education, depression, and previous substance use as mediating variables. Results: There were significant indirect associations between maternal ACEs and maternal substance use in pregnancy via maternal education (β = 0.05, p < 0.001), previous substance use (β = 0.01, p = 0.001), and depression (β = 0.02, p = 0.02). The direct effect of maternal ACEs on maternal substance in pregnancy remained significant after accounting for the indirect effects (β = 0.22, 95% CI = 0.15-0.29, p < 0.001). Conclusions: Exposure to adversity in childhood can lead to socioeconomic and mental health difficulties that increase risk for substance use in pregnancy. Addressing these difficulties before pregnancy may help to reduce the potential for substance use in pregnancy.

No. 349-Substance Use in Pregnancy

OBJECTIVES

To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers.

OPTIONS

This guideline reviews the use of screening tools, general approach to care, and recommendations for the clinical management of problematic substance use in pregnancy.

OUTCOMES

Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation.

EVIDENCE

Updates in the literature were retrieved through searches of Medline, PubMed, and The Cochrane Library published from 1996 to 2016 using the following key words: pregnancy, electronic cigarettes, tobacco use cessation products, buprenorphine, and methadone. Results were initially restricted to systematic reviews and RCTs/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report.

BENEFITS, HARMS, AND COSTS

This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care lead to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

RECOMMENDATIONS

Sustaining Engagement in Longitudinal Research With Vulnerable Families: A Mixed-Methods Study of Attrition

The aim of this mixed-methods study was to investigate attrition at the age 10-year follow-up in a study of vulnerable children and their families living with low income following a two-generation preschool program in Calgary, Alberta, Canada. Quantitative factors associated with attrition included: (a) food bank use; (b) unstable housing; (c) child welfare involvement; (d) unpartnered status; and (e) caregiver noncompletion of high school. Qualitative themes related to attrition included: (a) income and employment; (b) health; (c) unstable housing; (d) change of guardianship; (e) domestic violence; (f) work and time management challenges; and (g) negative caregiver-child relationships. Triangulation of quantitative and qualitative results occurred using Maslow's Hierarchy of Needs; families with unmet physiological, safety, belongingness and love needs, and esteem needs were more likely to attrite. Attrition in longitudinal studies with vulnerable families is complex, affected by frequently changing life circumstances, and struggles to access necessities of life. Strategies for retaining vulnerable families in longitudinal research are offered.

No 349 - Consommation de substances psychoactives pendant la grossesse

OBJECTIFS

Accroître la sensibilisation à la consommation problématique de substances psychoactives pendant la grossesse et les connaissances à ce sujet, et formuler des recommandations factuelles relatives à la prise en charge de cet épineux problème clinique à l'intention de l'ensemble des fournisseurs de soins.

OPTIONS

La présente directive clinique analyse l'utilisation d'outils de dépistage, l'approche générale de soins et les recommandations pour la prise en charge clinique de la consommation problématique de substances psychoactives pendant la grossesse.

ISSUES

Recommandations factuelles pour le dépistage et la prise en charge de la consommation problématique de substances psychoactives pendant la grossesse et l'allaitement.

RECHERCHE DOCUMENTAIRE

La littérature à jour a été obtenue au moyen de recherches dans Medline, PubMed et la Bibliothèque Cochrane visant les articles publiés entre 1996 et 2016, avec les mots clés suivants : « pregnancy », « electronic cigarettes », « tobacco use cessation products », « buprenorphine » et « methadone ». Les résultats ont d'abord été restreints aux analyses systématiques, aux ECR et aux essais cliniques contrôlés. Ensuite, en raison de la rareté des ECR sur le sujet, des recherches d'études observationnelles ont également été menées. Les articles sélectionnés ont été limités aux études chez l'humain publiées en anglais, puis d'autres articles ont été trouvés manuellement, par l'analyse des listes de références.

VALEURS

La qualité des données a été évaluée au moyen des critères énoncés dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. Les recommandations visant la pratique ont été classées conformément à la méthode décrite dans ce rapport. AVANTAGES, DéSAVANTAGES ET COûTS: La présente directive clinique a pour but d'améliorer les connaissances et le degré d'aisance des fournisseurs qui dispensent des soins aux femmes enceintes ayant un trouble de l'usage d'une substance. L'amélioration de l'accès aux soins de santé et de l'aide pour obtenir un traitement adéquat de la dépendance fait diminuer les coûts de santé et les taux de morbidité et de mortalité chez la mère et l'enfant. RECOMMANDATIONS.

Inadequate prenatal care use among Canadian mothers: findings from the Maternity Experiences Survey

OBJECTIVE

This study aims to investigate predictors of inadequate prenatal care (PNC) use among pregnant women in Canada.

STUDY DESIGN

Data for this secondary analysis was drawn from the Maternity Experiences Survey, a cross sectional, nationally representative survey that assessed peri- and post-natal experiences of mothers aged 15 and above in the Canadian provinces and territories. PNC use was measured by the Adequacy of Prenatal Care Utilization Index. Multivariate logistic regression analysis was conducted to determine socio-economic, demographic, maternal, delivery related and health service characteristics associated with inadequate PNC use.

RESULTS

Prevalence of inadequate PNC was at 18.9%. Regression analysis revealed that mothers who were immigrants (odds ratio (OR)=1.40; 95% (confidence interval) CI: 1.13-1.74), primiparous (OR=1.22; 95% CI: 1.04-1.44), smoked (OR=1.33; 95% CI: 1.04-1.69) or consumed alcohol (OR=1.32; 95% CI: 1.03-1.68) during their pregnancy were more likely to receive inadequate PNC. Mothers with a family doctor as PNC provider versus those with an obstetrician (OR=1.26; 95% CI: 1.08-1.48) were more likely to have inadequate PNC.

CONCLUSIONS

This is the first nationwide study in Canada to examine the factors associated with inadequate PNC use. Results of this study may help design interventions that target women with profiles of socio-demographic and behavioral risk to optimize their PNC use.

Health system and community level interventions for improving antenatal care coverage and health outcomes

BACKGROUND

The World Health Organization (WHO) recommends at least four antenatal care (ANC) visits for all pregnant women. Almost half of pregnant women worldwide, and especially in developing countries do not receive this amount of care. Poor attendance of ANC is associated with delivery of low birthweight babies and more neonatal deaths. ANC may include education on nutrition, potential problems with pregnancy or childbirth, child care and prevention or detection of disease during pregnancy.This review focused on community-based interventions and health systems-related interventions.

OBJECTIVES

To assess the effects of health system and community interventions for improving coverage of antenatal care and other perinatal health outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 June 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised trials and cluster-randomised trials. Trials of any interventions to improve ANC coverage were eligible for inclusion. Trials were also eligible if they targeted specific and related outcomes, such as maternal or perinatal death, but also reported ANC coverage.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We included 34 trials involving approximately 400,000 women. Some trials tested community-based interventions to improve uptake of antenatal care (media campaigns, education or financial incentives for pregnant women), while other trials looked at health systems interventions (home visits for pregnant women or equipment for clinics). Most trials took place in low- and middle-income countries, and 29 of the 34 trials used a cluster-randomised design. We assessed 30 of the 34 trials as of low or unclear overall risk of bias. Comparison 1: One intervention versus no interventionWe found marginal improvements in ANC coverage of at least four visits (average odds ratio (OR) 1.11, 95% confidence interval (CI) 1.01 to 1.22; participants = 45,022; studies = 10; Heterogeneity: Tau² = 0.01; I² = 52%; high quality evidence). Sensitivity analysis with a more conservative intra-cluster correlation co-efficient (ICC) gave similar marginal results. Excluding one study at high risk of bias shifted the marginal pooled estimate towards no effect. There was no effect on pregnancy-related deaths (average OR 0.69, 95% CI 0.45 to 1.08; participants = 114,930; studies = 10; Heterogeneity: Tau² = 0.00; I² = 0%; low quality evidence), perinatal mortality (average OR 0.98, 95% CI 0.90 to 1.07; studies = 15; Heterogeneity: Tau² = 0.01; I² = 58%; moderate quality evidence) or low birthweight (average OR 0.94, 95% CI 0.82 to 1.06; studies = five; Heterogeneity: Tau² = 0.00; I² = 5%; high quality evidence). Single interventions led to marginal improvements in the number of women who delivered in health facilities (average OR 1.08, 95% CI 1.02 to 1.15; studies = 10; Heterogeneity: Tau² = 0.00; I² = 0%; high quality evidence), and in the proportion of women who had at least one ANC visit (average OR 1.68, 95% CI 1.02 to 2.79; studies = six; Heterogeneity: Tau² = 0.24; I² = 76%; moderate quality evidence). Results for ANC coverage (at least four and at least one visit) and for perinatal mortality had substantial statistical heterogeneity. Single interventions did not improve the proportion of women receiving tetanus protection (average OR 1.03, 95% CI 0.92 to 1.15; studies = 8; Heterogeneity: Tau² = 0.01; I² = 57%). No study reported onintermittent prophylactic treatment for malaria. Comparison 2: Two or more interventions versus no interventionWe found no improvements in ANC coverage of four or more visits (average OR 1.48, 95% CI 0.99 to 2.21; participants = 7840; studies = six; Heterogeneity: Tau² = 0.10; I² = 48%; low quality evidence) or pregnancy-related deaths (average OR 0.70, 95% CI 0.39 to 1.26; participants = 13,756; studies = three; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence). However, combined interventions led to improvements in ANC coverage of at least one visit (average OR 1.79, 95% CI 1.47 to 2.17; studies = five; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence), perinatal mortality (average OR 0.74, 95% CI 0.57 to 0.95; studies = five; Heterogeneity: Tau² = 0.06; I² = 83%; moderate quality evidence) and low birthweight (average OR 0.61, 95% CI 0.46 to 0.80; studies = two; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence). Meta-analyses for both ANC coverage four or more visits and perinatal mortality had substantial statistical heterogeneity. Combined interventions improved the proportion of women who had tetanus protection (average OR 1.48, 95% CI 1.18 to 1.87; studies = 3; Heterogeneity: Tau² = 0.01; I² = 33%). No trial in this comparison reported on intermittent prophylactic treatment for malaria. Comparison 3: Two interventions compared head to head. No trials found. Comparison 4: One intervention versus a combination of interventionsThere was no difference in ANC coverage (four or more visits and at least one visit), pregnancy-related deaths, deliveries in a health facility or perinatal mortality. No trials in this comparison reported on low birthweight orintermittent prophylactic treatment of malaria.

AUTHORS' CONCLUSIONS

Implications for practice - Single interventions may improve ANC coverage (at least one visit and four or more visits) and deliveries in health facilities. Combined interventions may improve ANC coverage (at least one visit), reduce perinatal mortality and reduce the occurrence of low birthweight. The effects of the interventions are unrelated to whether they are community or health system interventions. Implications for research - More details should be provided in reporting numbers of events, group totals and the ICCs used to adjust for cluster effects. Outcomes should be reported uniformly so that they are comparable to commonly-used population indicators. We recommend further cluster-RCTs of pregnant women and women in their reproductive years, using combinations of interventions and looking at outcomes that are important to pregnant women, such as maternal and perinatal morbidity and mortality, alongside the explanatory outcomes along the pathway of care: ANC coverage, the services provided during ANC and deliveries in health facilities.

Predictors of Study Attrition in a Randomized Controlled Trial Evaluating a Perinatal Home-Visiting Program with Mothers with Psychosocial Vulnerabilities

Objective

Randomised controlled trials evaluating perinatal home-visiting programs are frequently confronted with the problem of high attrition rates. The aim of the present study is to identify predictors of study attrition in a trial evaluating a perinatal home-visiting program in France.

Materials and Methods

CAPEDP is a French randomized trial comparing a perinatal home-visiting program using psychologists versus usual care (N = 440). The first assessment was at inclusion into the trial at the 27^th week of pregnancy and the final assessment when the child reached the age of two. Attrition rates were calculated at 3 and 24 months postpartum. Stepwise logistic regression was used to identify predictors of early (between inclusion and 3 months postpartum) and later (between 3 and 24 months postpartum) attrition among social, psychological and parenting factors.

Results

Attrition rates were 17% and 63% at 3 and 24 months respectively. At 24 months, there was significantly more attrition in the control arm (70.6%) compared to the intervention arm (55.2%). Five independent predictors of early attrition were identified: having already had an abortion; having greater attachment insecurity as measured with the Vulnerable Attachment Style Questionnaire (VASQ); having lower global severity of psychiatric symptoms as assessed with the Symptom Check-List (SCL-90) at inclusion, being neither currently employed nor studying; and declaring no tobacco consumption during pregnancy. Being randomized into the control arm, having undergone early parental loss before age 11 and having lower global severity of psychiatric symptoms (SCL-90) at 3 months postpartum were the only variables associated with later attrition.

Conclusion

This study provides key information for identifying mothers who may require specific support to avoid study attrition in trials evaluating a home-visiting program.

Impact of Self-Help Schema Therapy on Psychological Distress and Early Maladaptive Schemas: A Randomised Controlled Trial

Self-help cognitive behaviour therapy has been found helpful in treating anxiety and depression. Recent evidence suggests that self-help schema therapy may represent another treatment alternative. The present study aimed to provide a preliminary assessment of the efficacy of self-help schema therapy on psychological distress and early maladaptive schemas (EMSs) using a 6-week treatment protocol with minimal email contact. Method: Participants were recruited from the general population and randomly assigned to self-help schema therapy (n = 32) or a waitlist (n = 32). Intent-to-treat analyses and study completer analyses were conducted using repeated-measures analyses of variance (time × group). Results: Intent-to-treat analyses revealed that treatment produced a marginal improvement in distress, but no change in EMSs. Among study completers (n = 34), self-help schema therapy yielded large reductions in distress scores on the Outcome Questionnaire-45.2 (partial eta squared = .16). Compared to the waitlist, self-help schema therapy also produced a moderate decrease in EMSs (partial eta squared = .10). The majority of study completers showed reliable clinical change in distress and reported high levels of satisfaction with the intervention. Conclusion: Self-help schema therapy may be an effective treatment for those individuals who persist in treatment. Self-help schema therapy has the potential to help a large number of individuals who may not otherwise have access to services. More research is needed to determine variables associated with treatment adherence and successful outcome.

What patterns of postpartum psychological distress are associated with maternal concerns about their children's emotional and behavioural problems at the age of three years?

Mothers experiencing psychological distress in the postpartum period may have difficulties parenting their children. Inconsistent and unresponsive parenting may increase the risk of later emotional and behavioural problems in children. The purpose of this study was to identify how maternal psychological characteristics cluster at eight weeks postpartum, and whether these clusters were associated with maternal-reported child emotional and behavioural problems at the age of three years, as measured by the Parents' Evaluation of Developmental Status (PEDS) questionnaire. In a longitudinal pregnancy cohort (N = 647), three clusters of postpartum psychological characteristics were identified. Contrary to expectations, mothers with the greatest psychological distress did not report concerns about their child's emotional and behavioural problems; rather, they reported concerns about global developmental delay. These findings suggest that infants of mothers experiencing postpartum psychological distress should receive additional follow-up to reduce the risk for global developmental delay.

Early childhood risk and resilience factors for behavioural and emotional problems in middle childhood

BACKGROUND

Mental disorders in childhood have a considerable health and societal impact but the associated negative consequences may be ameliorated through early identification of risk and protective factors that can guide health promoting and preventive interventions. The objective of this study was to inform health policy and practice through identification of demographic, familial and environmental factors associated with emotional or behavioural problems in middle childhood, and the predictors of resilience in the presence of identified risk factors.

METHODS

A cohort of 706 mothers followed from early pregnancy was surveyed at six to eight years post-partum by a mail-out questionnaire, which included questions on demographics, children's health, development, activities, media and technology, family, friends, community, school life, and mother's health.

RESULTS

Although most children do well in middle childhood, of 450 respondents (64% response rate), 29.5% and 25.6% of children were found to have internalising and externalising behaviour problem scores in the lowest quintile on the NSCLY Child Behaviour Scales. Independent predictors for problem behaviours identified through multivariable logistic regression modelling included being male, demographic risk, maternal mental health risk, poor parenting interactions, and low parenting morale. Among children at high risk for behaviour problems, protective factors included high maternal and child self-esteem, good maternal emotional health, adequate social support, good academic performance, and adequate quality parenting time.

CONCLUSIONS

These findings demonstrate that several individual and social resilience factors can counter the influence of early adversities on the likelihood of developing problem behaviours in middle childhood, thus informing enhanced public health interventions for this understudied life course phase.

Antenatal psychosomatic programming to reduce postpartum depression risk and improve childbirth outcomes: a randomized controlled trial in Spain and France

Background

Postpartum depression (PPD) and poor childbirth outcomes are associated with poverty; these variables should be addressed by an adapted approach. The aim of this research was to evaluate the impact of an antenatal programme based on a novel psychosomatic approach to pregnancy and delivery, regarding the risk of PPD and childbirth outcomes in disadvantaged women.

Methods

A multi-centre, randomized, controlled trial comparing a novel to standard antenatal programme. Primary outcome was depressive symptoms (using EPDS) and secondary outcome was preterm childbirth (fewer 37 weeks). The sample comprised 184 couples in which the women were identified to be at PPD risk by validated interview. The study was conducted in three public hospitals with comparable standards of perinatal care. Women were randomly distributed in to an experimental group (EG) or a control group (CG), and evaluated twice: during pregnancy (T1) and four weeks post-partum (T2). At T2, the variables were compared using the chi square test. Data analysis was based on intention to treat. The novel programme used the Tourné psychosomatic approach focusing on body awareness sensations, construction of an individualized childbirth model, and attachment. The 10 group antenatal sessions each lasted two hours, with one telephone conversation between sessions. In the control group, the participants choose the standard model of antenatal education, i.e., 8 to 10 two-hour sessions focused on childbirth by obstetrical prophylaxis.

Results

A difference of 11.2% was noted in postpartum percentages of PPD risk (EPDS ≥ 12): 34.3% (24) in EG and 45.5% (27) in CG (p = 0.26). The number of depressive symptoms among EG women decreased at T₂ (intragroup p = 0.01). Premature childbirth was four times less in EG women: three (4.4%) compared to 13 (22.4%) among CG women (p = 0.003). Birth weight was higher in EG women (p = 0.01).

Conclusions

The decrease of depressive symptoms in women was not conclusive. However, because birth weight was higher and the rate of preterm childbirth was lower in the EG, our results suggest that the psychosomatic approach may be more helpful to the target population than the standard antenatal programs.

How to Undertake Research of MHC Utilization in Under-developed Countries? A Case Study of MHC Utilization in Central and Western Rural China

OBJECTIVE

This study was undertaken to address practical problems in maternal health care (MHC) utilization and conduct in-depth study of maternal health services utilization in underdeveloped countries(regions), thus to contribute to the achieving of the UN Millennium Development Goal 5.

DATA COLLECTION

After searching and screening based on key words like "MHC" and "utilization", we included 45 English articles and 106 Chinese articles from Pubmed, Medline, China Knowledge Resource Integrated and Wang Fang data base. The research themes, issues, designs, perspectives, dimensions and methods of these dissertations were analyzed.

RESULTS

The development of MHC utilization research can be divided into three phases: Studies of the first phase focused primarily on decreasing MMR, which caused attention to the central and western rural areas maternal health services in China from domestic as well as international community; Studies of the second phase centered around the practical impacts of the implementation of MHC relevant programs and policy, confirming that the implementation of these programs and policies improved MHC service delivery and utilization, and promoted cooperation between researchers and practitioners; Studies of the third phase focused on the quality of MHC service utilization. We also found that the major problem in the current MHC service utilization is the huge gap across regions and the existing researches lack innovation and comparison researches between in different countries.

CONCLUSION

Research themes of MHC services change regularly. We should grasp the characteristics and defects of current research to increase the innovation of future research and to better response to the problem solving, and thus to provide more valuable reference for the policy and practice of underdeveloped countries and areas.

A comparative analysis of early child health and development services and outcomes in countries with different redistributive policies

Background

The social environment is a fundamental determinant of early child development and, in turn, early child development is a determinant of health, well-being, and learning skills across the life course. Redistributive policies aimed at reducing social inequalities, such as a welfare state and labour market policies, have shown a positive association with selected health indicators. In this study, we investigated the influence of redistributive policies specifically on the social environment of early child development in five countries with different political traditions. The objective of this analysis was to highlight similarities and differences in social and health services between the countries and their associations with other health outcomes that can inform better global early child development policies and improve early child health and development.

Methods

Four social determinants of early child development were selected to provide a cross-section of key time periods in a child’s life from prenatal to kindergarten. They included: 1) prenatal care, 2) maternal leave, 3) child health care, and 4) child care and early childhood education. We searched international databases and reports (e.g. Organization for Economic Cooperation and Development, World Bank, and UNICEF) to obtain information about early child development policies, services and outcomes.

Results

Although a comparative analysis cannot claim causation, our analysis suggests that redistributive policies aimed at reducing social inequalities are associated with a positive influence on the social determinants of early child development. Generous redistributive policies are associated with a higher maternal leave allowance and pay and more preventive child healthcare visits. A decreasing trend in infant mortality, low birth weight rate, and under five mortality rate were observed with an increase in redistributive policies. No clear influence of redistributive policies was observed on breastfeeding and immunization rates. In the analysis of child care and early education, the lack of uniform measures of early child development outcomes was apparent.

Conclusions

This paper provides further support for an association between redistributive policies and early child health and development outcomes, along with the organization of early child health and development services.

Exploring the group prenatal care model: a critical review of the literature

Few studies have compared perinatal outcomes between individual prenatal care and group prenatal care. A critical review of research articles that were published between 1998 and 2009 and involved participants of individual and group prenatal care was conducted. Two middle range theories, Pender's health promotion model and Swanson's theory of caring, were blended to enhance conceptualization of the relationship between pregnant women and the group prenatal care model. Among the 17 research studies that met inclusion criteria for this critical review, five examined gestational age and birth weight with researchers reporting longer gestations and higher birth weights in infants born to mothers participating in group prenatal care, especially in the preterm birth population. Current evidence demonstrates that nurse educators and leaders should promote group prenatal care as a potential method of improving perinatal outcomes within the pregnant population.

Street drug use during pregnancy: potential programming effects on preschool wheeze

Street drug use during pregnancy is detrimental to fetal development. Although the prevalence of wheeze is high in offspring of substance-abusing mothers, nothing is known about the role of street drug use during pregnancy in its development. We investigated the impact of maternal street drug use and distress during pregnancy on the development of wheeze and allergy in preschool children. Questionnaire data were accessed from the Community Perinatal Care trial of 791 mother–child pairs in Calgary, Alberta. Using logistic regression, the association between maternal substance use and distress during pregnancy, and wheeze and allergy at age 3 years was determined in boys and girls. After adjusting for alcohol use during pregnancy, pre- and postnatal tobacco use, preterm birth, duration of exclusive breastfeeding, daycare attendance and maternal socioeconomic status, maternal street drug use during pregnancy [odds ratio (OR): 5.02, 95% confidence interval (CI): 1.30–19.4] and severe maternal distress during pregnancy (OR: 5.79, 95% CI: 1.25–26.8) were associated with wheeze in girls. In boys, an independent association was found between severe distress during pregnancy (OR: 3.85, 95% CI: 1.11–13.3) and allergies, but there was no association with maternal street drug use. In conclusion, we found an association between maternal street drug use and wheeze in preschool girls that could not be accounted for by maternal distress, smoking or alcohol use during pregnancy. Prenatal programming effects of street drugs may explain this association.

[Preventing the risk of postpartum depression and premature childbirth by a psychosomatic approach: a randomized multicenter study]

BACKGROUND AND OBJECTIVE

Randomized studies to assess postnatal depression and preterm childbirth are rarely in conjunction; the 2 problems are treated separately regardless of their common risk factors. The main objective of this study was to evaluate the effects of a prenatal program based on a psychosomatic approach on the risk of postpartum depression (PPD) and preterm childbirth.

SUBJECTS AND METHOD

Controlled clinical trial, randomized and multicenter study. A total of 184 pregnant women identified as vulnerable to PPD who had psychosocial risk factors associated with preterm childbirth were assigned to the experimental group (EG) (n=92) or control group (CG) (n=92), according to a computerized program. The EG participated in the program with a psychosomatic approach (10 sessions (one/week) for 2 h, 15 m) with a phone call between sessions; the objectives implicated the mother, father and baby contemplating pregnancy, childbirth and postpartum. Women in the EC made the usual program of the health center (8-10 weekly sessions of 2 hours), with no calls, with targets aimed at delivery. There were 2 evaluations: one in pregnancy and another in postpartum (T(1) and T(2)) including symptoms of depression (EPDS), social support (FSSQ), stress (scale events), the relationship (DAS) and the preterm childbirth.

RESULTS

There was a difference of 11.2 in the percentage of cases at risk of PPD (EPDS≥12): 45.5% (27) in the CG and 34.3% (24) in the EG, without reaching statistical significance (P=.26). The preterm delivery showed significance differences (P=.003), with a decrease in preterm childbirth 4 times lower in the EG.

CONCLUSIONS

Overall, the percentage of mothers at PPD risk was higher (P=.02) in women with preterm childbirth. It would be appropriate a global obstetrics and psychiatry approach.

SOGC clinical practice guidelines: Substance use in pregnancy: no. 256, April 2011

OBJECTIVE

To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers.

OPTIONS

This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy.

OUTCOMES

Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation.

EVIDENCE

Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1).

BENEFITS, HARMS, AND COSTS

This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

Regional disparities in prenatal care services in rural China

The study compared the prenatal care programs in the Central-East, Northwest, and Southwest regions of China. Data were collected on 14 indicators of the quality of the prenatal care process, as well as the percentage of women with high-risk pregnancies who were screened. The average number of prenatal examinations for those women who received prenatal care was 5.01, and 62.6% of pregnant women had their first examination within 12 weeks of their pregnancy. About 35% of these pregnant women had at least 1 high-risk screening, and 20.8% had 3 high-risk screenings. Among the 3 regions, the Central-East region had the best overall quality prenatal services, and the Northwest area had the poorest quality. The quality of prenatal health care in poor, rural China is in need of improvement.

Substance use in pregnancy

OBJECTIVE

To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers.

OPTIONS

This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy.

OUTCOMES

Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation.

EVIDENCE

Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1).

BENEFITS, HARMS, AND COSTS

This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

RECOMMENDATIONS

1. All pregnant women and women of childbearing age should be screened periodically for alcohol, tobacco, and prescription and illicit drug use. (III-A) 2. When testing for substance use is clinically indicated, urine drug screening is the preferred method. (II-2A) Informed consent should be obtained from the woman before maternal drug toxicology testing is ordered. (III-B) 3. Policies and legal requirements with respect to drug testing of newborns may vary by jurisdiction, and caregivers should be familiar with the regulations in their region. (III-A) 4. Health care providers should employ a flexible approach to the care of women who have substance use problems, and they should encourage the use of all available community resources. (II-2B) 5. Women should be counselled about the risks of periconception, antepartum, and postpartum drug use. (III-B) 6. Smoking cessation counselling should be considered as a first-line intervention for pregnant smokers. (I-A) Nicotine replacement therapy and/or pharmacotherapy can be considered if counselling is not successful. (I-A) 7. Methadone maintenance treatment should be standard of care for opioid-dependent women during pregnancy. (II-IA) Other slow-release opioid preparations may be considered if methadone is not available. (II-2B) 8. Opioid detoxification should be reserved for selected women because of the high risk of relapse to opioids. (II-2B) 9. Opiate-dependent women should be informed that neonates exposed to heroin, prescription opioids, methadone, or buprenorphine during pregnancy are monitored closely for symptoms and signs of neonatal withdrawal (neonatal abstinence syndrome). (II-2B) Hospitals providing obstetric care should develop a protocol for assessment and management of neonates exposed to opiates during pregnancy. (III-B) 10. Antenatal planning for intrapartum and postpartum analgesia may be offered for all women in consultation with appropriate health care providers. (III-B) 11. The risks and benefits of breastfeeding should be weighed on an individual basis because methadone maintenance therapy is not a contraindication to breastfeeding. (II-3B).

All Our Babies Cohort Study: recruitment of a cohort to predict women at risk of preterm birth through the examination of gene expression profiles and the environment

Background

Preterm birth is the leading cause of perinatal morbidity and mortality. Risk factors for preterm birth include a personal or familial history of preterm delivery, ethnicity and low socioeconomic status yet the ability to predict preterm delivery before the onset of preterm labour evades clinical practice. Evidence suggests that genetics may play a role in the multi-factorial pathophysiology of preterm birth. The All Our Babies Study is an on-going community based longitudinal cohort study that was designed to establish a cohort of women to investigate how a women's genetics and environment contribute to the pathophysiology of preterm birth. Specifically this study will examine the predictive potential of maternal leukocytes for predicting preterm birth in non-labouring women through the examination of gene expression profiles and gene-environment interactions.

Methods/Design

Collaborations have been established between clinical lab services, the provincial health service provider and researchers to create an interdisciplinary study design for the All Our Babies Study. A birth cohort of 2000 women has been established to address this research question. Women provide informed consent for blood sample collection, linkage to medical records and complete questionnaires related to prenatal health, service utilization, social support, emotional and physical health, demographics, and breast and infant feeding. Maternal blood samples are collected in PAXgene™ RNA tubes between 18-22 and 28-32 weeks gestation for transcriptomic analyses.

Discussion

The All Our Babies Study is an example of how investment in clinical-academic-community partnerships can improve research efficiency and accelerate the recruitment and data collection phases of a study. Establishing these partnerships during the study design phase and maintaining these relationships through the duration of the study provides the unique opportunity to investigate the multi-causal factors of preterm birth. The overall All Our Babies Study results can potentially lead to healthier pregnancies, mothers, infants and children.

Recruitment and retention of women in a large randomized control trial to reduce repeat preterm births: the Philadelphia Collaborative Preterm Prevention Project

BACKGROUND

Recruitment and retention of patients for randomized control trial (RCT) studies can provide formidable challenges, particularly with minority and underserved populations. Data are reported for the Philadelphia Collaborative Preterm Prevention Project (PCPPP), a large RCT targeting risk factors for repeat preterm births among women who previously delivered premature (< 35 weeks gestation) infants.

METHODS

Design of the PCPPP incorporated strategies to maximize recruitment and retention. These included an advanced database system tracking follow-up status and assessment completion rates; cultural sensitivity training for staff; communication to the community and eligible women of the benefits of participation; financial incentives; assistance with transportation and supervised childcare services; and reminder calls for convenient, flexibly scheduled appointments. Analyses reported here: 1) compare recruitment projections to actual enrollment 2) explore recruitment bias; 3) validate the randomization process 4) document the extent to which contact was maintained and complete assessments achieved 5) determine if follow-up was conditioned upon socio-economic status, race/ethnicity, or other factors.

RESULTS

Of eligible women approached, 1,126 (77.7%) agreed to participate fully. Of the 324 not agreeing, 118 (36.4%) completed a short survey. Consenting women were disproportionately from minority and low SES backgrounds: 71.5% consenting were African American, versus 38.8% not consenting. Consenting women were also more likely to report homelessness during their lifetime (14.6% vs. 0.87%) and to be unmarried at the time of delivery (81.6% versus 47.9%). First one-month postpartum assessment was completed for 83.5% (n = 472) of the intervention group (n = 565) and 76% (426) of the control group. Higher assessment completion rates were observed for the intervention group throughout the follow-up. Second, third, fourth and fifth postpartum assessments were 67.6% vs. 57.5%, 60.0% vs. 48.9%, 54.2% vs. 46.3% and 47.3% vs. 40.8%, for the intervention and control group women, respectively. There were no differences in follow-up rates according to race/ethnicity, SES or other factors. Greater retention of the intervention group may reflect the highly-valued nature of the medical and behavior services constituting the intervention arms of the Project.

CONCLUSION

Findings challenge beliefs that low income and minority women are averse to enrolling and continuing in clinical trials or community studies.

Maternal well-being and its association to risk of developmental problems in children at school entry

BACKGROUND

Children at highest risk of developmental problems benefit from early identification and intervention. Investigating factors affecting child development at the time of transition to school may reveal opportunities to tailor early intervention programs for the greatest effectiveness, social benefit and economic gain. The primary objective of this study was to identify child and maternal factors associated with children who screened at risk of developmental problems at school entry.

METHODS

An existing cohort of 791 mothers who had been followed since early pregnancy was mailed a questionnaire when the children were aged four to six years. The questionnaire included a screening tool for developmental problems, an assessment of the child's social competence, health care utilization and referrals, and maternal factors, including physical health, mental health, social support, parenting morale and sense of competence, and parenting support/resources.

RESULTS

Of the 491 mothers (62%) who responded, 15% had children who were screened at high risk of developmental problems. Based on a logistic regression model, independent predictors of screening at high risk for developmental problems at age 5 were male gender (OR: 2.3; 95% CI: 1.3, 4.1), maternal history of abuse at pregnancy (OR: 2.4; 95% CI: 1.3, 4.4), and poor parenting morale when the child was 3 years old (OR: 3.9; 95% CI: 2.1, 7.3). A child with all of these risk factors had a 35% predicted probability of screening at high risk of developmental problems, which was reduced to 13% if maternal factors were favourable.

CONCLUSIONS

Risk factors for developmental problems at school entry are related to maternal well being and history of abuse, which can be identified in the prenatal period or when children are preschool age.

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

BACKGROUND

Women with low incomes are at higher risk to have low-birthweight (LBW) babies and less likely to participate in prenatal support programmes than women with higher incomes. This study examined birth outcomes among participants in the Newfoundland and Labrador Mother-Baby Nutrition Supplement (MBNS), a prenatal programme for women with low incomes that provides a monthly financial supplement and printed information on infant health and development, along with a referral to public health nursing services.

METHODS

Application data (e.g. mother's age, education) for those who applied between August 2002 and December 2004 were obtained from the Provincial Government. Birth outcomes (e.g. birthweight, weeks of gestation) were available for 1599 women. Of these, 862 were parity zero and subsequently delivered full-term infants. Comparisons were made on demographics, timeliness of enrolment and rates of full-term LBW.

RESULTS

Participants were more often single, younger and less educated than the average woman who gave birth in the Province or Canada in 2004. Women enrolled early were less likely to have a full-term LBW baby than those enrolled late (chi(2)((1)) = 4.03, P = 0.045). Mothers enrolled late had a higher rate of full-term LBW than was the case in the Province [risk ratio (RR) = 2.76, 95% confidence interval (CI) = 1.61-4.74] and Canada (RR = 2.53, 95% CI = 1.55-4.21) whereas those enrolled earlier, despite increased risk due to low income, age and education, single status and zero parity, had rates of full-term LBW on par with the Province (RR = 1.29, 95% CI = 0.71-2.32) and Canada (RR = 1.19, 95% CI = 0.68-2.08).

CONCLUSION

The MBNS is an effective intervention for improving birth outcomes in women considered at risk. The challenge is to enrol pregnant women as early as possible. Future research will examine what programme component or combination of components (e.g. financial, information, referral) affects birth outcomes.

Newborn screening for non-sickling hemoglobinopathies

The hemoglobinopathies encompass a heterogeneous group of disorders associated with mutations in both the alpha-globin and beta-globin genes. Non-sickling disorders are found primarily in individuals of Mediterranean, Asian and Southeast Asian ancestry. With rapid growth in the Asian and Hispanic segments of the US population, the geographic distribution of hemoglobinopathies is expected to become significantly different from what it is today. The epidemiologic changes in the prevalence of non-sickling hemoglobin disorders have important implications for future public health programs, including newborn screening.

The purpose of newborn screening for hemoglobinopathies is to identify clinically significant disorders and provide early education and specialized care prior to the onset of clinical symptoms. Although newborn screening for sickle cell disease is mandated in all states, screening for non-sickling hemoglobinopathies is directed in only one state and limited to reporting of a presumptive diagnosis in most other states. Early delivery of comprehensive care, as well as new and potentially curative therapies, has significantly improved the prognosis for affected patients. This review will consider the increasing prevalence of once uncommon hemoglobinopathies in the US, highlighting the rationale for expanding newborn screening beyond sickle cell disorders.