Using Web-Based Questionnaires and Obstetric Records to Assess General Health Characteristics Among Pregnant Women: A Validation Study

A comparison of infants' birth defects self-reported by mothers with data provided by general practitioners: Data from the Dutch Pregnancy Drug Register

BACKGROUND

Since the presence of a birth defect is often a primary outcome in drug-safety studies among pregnant women, researching the validity of data collection methods is imperative. The aim of this study is to compare self-reported birth defects in infants by mothers with the information provided by general practitioners (GP (singular) or GPs (plural)).

METHODS

Mothers who participated in the Dutch Pregnancy Drug Register reported information about possible birth defects of their infants via questionnaires. GPs were approached to provide information on possible birth defects of the same infants. All reported birth defects by mothers and GPs were blindly coded using the International Classification of Diseases, Tenth Revision (ICD-10) index and EUROCAT-classified as either a minor or major birth defect. Differences in reported birth defects between participants and GPs were assessed.

RESULTS

Participants and GPs (N = 551) reported 67 and 53 birth defects respectively, leading to a total of 120 birth defects among 65 infants. When both the GP and the participant reported a birth defect, 76.9% of these birth defects (N = 60) were coded with an identical ICD-10 code. Information on the absence of a birth defect and the presence of a major birth defect was identically reported by the GP and the mother in almost all cases (98.2%). Of the major birth defects reported by the GP, 67% could be matched with information provided by the participant, for 33% contradicting information was reported.

CONCLUSION

Self-reported questionnaire data on infants' birth defects from mothers yield fairly similar information compared to information obtained through GPs. Future studies should validate the accuracy of self-reported birth defects by mothers more extensively to improve the quality of drug safety studies during pregnancy.

Maternal first trimester COVID-19 vaccination and risk of major non-genetic congenital anomalies

BACKGROUND

Information regarding the risk of early pregnancy COVID-19 vaccination on the development of major congenital anomalies in the offspring is still limited. Here, we study the association between any COVID-19 vaccination during the 1st trimester and at least one major non-genetic congenital anomaly in the offspring.

METHODS

We used data from the Dutch Pregnancy Drug Register, an ongoing cohort study. We selected participants with a pregnancy that ended after at least 20 weeks gestation. Pregnant participants self-reported their COVID-19 vaccination status and the presence of congenital anomalies in the offspring. We used logistic regression analyses to study the association between 1st trimester COVID-19 vaccination (gestational week 2 + 0 to 12 + 6) and the risk of at least one major non-genetic congenital anomaly in the offspring. Clustering of anomalies on the ICD10 level by 1st trimester COVID-19 vaccination status was explored using Fisher exact tests.

RESULTS

We included 3721 participants of whom 795 (21.4%) were COVID-19 vaccinated during the 1st trimester. The percentage of participants who gave birth to a child with at least one major non-genetic congenital anomaly was comparable between participants who were 1st trimester vaccinated (1.1%) and participants who were not (1.2%) (adjusted odd ratio 0.78 [95% confidence interval 0.35-1.71]). We found no clustering of major non-genetic congenital anomalies by 1st trimester COVID-19 vaccination status (p > .05).

CONCLUSIONS

There were no indications of an increased risk of major non-genetic congenital anomalies in the offspring after maternal 1st trimester COVID-19 vaccination. Our findings suggest COVID-19 vaccines are safe during early pregnancy.

Delayed entry into prenatal care among women with pre-pregnancy health conditions, National Birth Defects Prevention Study, 1997-2011

First trimester entry into prenatal care is recommended for all women, and especially women with pre-pregnancy conditions. Our objective was to determine whether women with pre-pregnancy conditions were at lower risk of entry after the first trimester (delayed entry) into prenatal care than women without a pre-pregnancy health condition. We used data from 10,890 participants in the National Birth Defects Prevention Study who delivered liveborn infants without birth defects. Women reported pre-pregnancy conditions and timing of entry into prenatal care during a computer-assisted telephone interview. Multivariable logistic regression analyses were conducted to evaluate whether having a pre-pregnancy condition was associated with delayed entry into prenatal care compared to women without pre-pregnancy conditions. Approximately 13% of women reported delayed entry into prenatal care, and 18% of women reported a pre-pregnancy condition. Delayed entry into prenatal care was not associated with pre-pregnancy cardiometabolic or neurologic conditions. Women with thyroid conditions were less likely to report delayed entry into prenatal care (prevalence odds ratio (OR), 95% confidence interval (CI): 0.55 [0.32, 0.94]), but women with hematologic and respiratory conditions were more likely to report delayed entry into prenatal care (OR: 1.95 [1.00, 3.82] and 1.27 [0.95, 1.72], respectively), compared to those without any chronic conditions. Future research investigating the success of early prenatal care among women with thyroid conditions could identify ways to reduce delayed prenatal care among women with other pre-pregnancy conditions.

The PRIDE Study: Evaluation of online methods of data collection

BACKGROUND

Large birth cohort studies are extremely valuable in assessing associations between early life exposures and long-term outcomes. Establishing new birth cohorts is challenging due to declining participation rates. Online methods of data collection may increase feasibility, but have not been evaluated thoroughly.

OBJECTIVE

The primary objective of the ongoing PRegnancy and Infant DEvelopment (PRIDE) Study is to identify exposures during pregnancy and in early life that may affect short-term or long-term health of mother and/or child. In this manuscript, we aimed to evaluate methods of recruitment and online data collection applied.

POPULATION

Dutch women aged ≥18 years in early pregnancy.

DESIGN

Prospective cohort study.

METHODS

Initially, only prenatal care providers recruited participants, but alternative recruitment methods were added as a result of disappointing participation rates, including collaboration with "Moeders voor Moeders" (organisation that visits women in early pregnancy) and Facebook advertisements. Data on demographic characteristics, obstetric history, maternal health, life style factors, occupational exposures, nutrition, pregnancy complications, and infant outcomes are primarily collected through Web-based questionnaires at multiple time points during and after pregnancy. Additional data collection components include paternal questionnaires, blood and saliva sampling, and linkage to medical records.

PRELIMINARY RESULTS

By September 2019, 9573 women were included in the PRIDE Study, of which 1.3% completed paper-based questionnaires. Mean age of the women analysed was 30.6 years, 71.1% had a high level of education, 57.2% were primiparae, and mean gestational age at enrolment was 9.9 (range 3, 37) weeks, with slight differences between recruitment methods. Pregnancy outcome was known for 89.8%. Retention rate at 6 months after the estimated date of delivery was estimated at 70%. Multiple validation studies conducted within the PRIDE Study indicated high data quality.

CONCLUSION(S)

Although challenging and time-consuming, online methods for recruitment and data collection may enable the establishment of new birth cohort studies.

Impact on perinatal health and cost-effectiveness of risk-based care in obstetrics: a before-after study

BACKGROUND

Obstetric health care relies on an adequate antepartum risk selection. Most guidelines used for risk stratification, however, do not assess absolute risks. In 2017, a prediction tool was implemented in a Dutch region. This tool combines first trimester prediction models with obstetric care paths tailored to the individual risk profile, enabling risk-based care.

OBJECTIVE

To assess impact and cost-effectiveness of risk-based care compared to care-as-usual in a general population.

METHODS

A before-after study was conducted using 2 multicenter prospective cohorts. The first cohort (2013-2015) received care-as-usual; the second cohort (2017-2018) received risk-based care. Health outcomes were (1) a composite of adverse perinatal outcomes and (2) maternal quality-adjusted life-years. Costs were estimated using a health care perspective from conception to 6 weeks after the due date. Mean costs per woman, cost differences between the 2 groups, and incremental cost effectiveness ratios were calculated. Sensitivity analyses were performed to evaluate the robustness of the findings.

RESULTS

In total 3425 women were included. In nulliparous women there was a significant reduction of perinatal adverse outcomes among the risk-based care group (adjusted odds ratio, 0.56; 95% confidence interval, 0.32-0.94), but not in multiparous women. Mean costs per pregnant woman were significantly lower for risk-based care (mean difference, -€2766; 95% confidence interval, -€3700 to -€1825). No differences in maternal quality of life, adjusted for baseline health, were observed.

CONCLUSION

In the Netherlands, risk-based care in nulliparous women was associated with improved perinatal outcomes as compared to care-as-usual. Furthermore, risk-based care was cost-effective compared to care-as-usual and resulted in lower health care costs.

An assessment of self-reported COVID-19 related symptoms of 227,898 users of a social networking service in Japan: Has the regional risk changed after the declaration of the state of emergency?

Background

In the absence of widespread testing, symptomatic monitoring efforts may allow for understanding the epidemiological situation of the spread of coronavirus disease 2019 (COVID-19) in Japan. We obtained data from a social networking service (SNS) messaging application that monitors self-reported COVID-19 related symptoms in real time in Fukuoka Prefecture, Japan. We aimed at not only understanding the epidemiological situation of COVID-19 in the prefecture, but also highlighting the usefulness of symptomatic monitoring approaches that rely on self-reporting using SNS during a pandemic, and informing the assessment of Japan's emergency declaration over COVID-19.

Methods

We analysed symptoms data (fever over 37.5° and a strong feeling of weariness or shortness of breath), reported voluntarily via SNS chatbot by 227,898 residents of Fukuoka Prefecture during March 27 to May 3, 2020, including April 7, when a state of emergency was declared. We estimated the spatial correlation coefficient between the number of the self-reported cases of COVID-19 related symptoms and the number of PCR confirmed COVID-19 cases in the period (obtained from the prefecture website); and estimated the empirical Bayes age- and sex-standardised incidence ratio (EBSIR) of the symptoms in the period, compared before and after the declaration. The number of symptom cases was weighted by age and sex to reflect the regional population distribution according to the 2015 national census.

Findings

Of the participants, 3.47% reported symptoms. There was a strong spatial correlation of 0.847 (p < 0.001) at municipality level between the weighted number of self-reported symptoms and the number of COVID-19 cases for both symptoms. The EBSIR at post-code level was not likely to change remarkably before and after the declaration of the emergency, but the gap in EBSIR between high-risk and low-risk areas appeared to have increased after the declaration.

Interpretation

While caution is necessary as the data was limited to SNS users, the self-reported COVID-19 related symptoms considered in the study had high epidemiological evaluation ability. In addition, though based on visual assessment, after the declaration of the emergency, regional containment of the infection risk might have strengthened to some extent. SNS, which can provide a high level of real-time, voluntary symptom data collection, can be used to assess the epidemiology of a pandemic, as well as to assist in policy assessments such as emergency declarations.

Funding

The present work was supported in part by a grant from the Ministry of Health, Labour and Welfare of Japan (H29-Gantaisaku-ippan-009).

External validation and clinical utility of prognostic prediction models for gestational diabetes mellitus: A prospective cohort study

Introduction

We performed an independent validation study of all published first trimester prediction models, containing non‐invasive predictors, for the risk of gestational diabetes mellitus. Furthermore, the clinical potential of the best performing models was evaluated.

Material and methods

Systemically selected prediction models from the literature were validated in a Dutch prospective cohort using data from Expect Study I and PRIDE Study. The predictive performance of the models was evaluated by discrimination and calibration. Clinical utility was assessed using decision curve analysis. Screening performance measures were calculated at different risk thresholds for the best model and compared with current selective screening strategies.

Results

The validation cohort included 5260 women. Gestational diabetes mellitus was diagnosed in 127 women (2.4%). The discriminative performance of the 12 included models ranged from 68% to 75%. Nearly all models overestimated the risk. After recalibration, agreement between the observed outcomes and predicted probabilities improved for most models.

Conclusions

The best performing prediction models showed acceptable performance measures and may enable more personalized medicine‐based antenatal care for women at risk of developing gestational diabetes mellitus compared with current applied strategies.

Aim and Design of pREGnant, the Dutch Pregnancy Drug Register

Information on the safety of medication use during pregnancy and breastfeeding is scarce, yet use of medication among pregnant and breastfeeding women is widespread. The pREGnant, the Dutch Pregnancy Drug Register, was set up to obtain insight into medication use among pregnant and breastfeeding women and potential effects on maternal and fetal/infant health. The systematically documented, good quality data on medication use during pregnancy and lactation in pREGnant will be used in signal detection, epidemiologic studies and counseling of healthcare providers and patients. The register has a prospective cohort design. The population is derived from pregnant women throughout the Netherlands. Data collection started in April 2014 and enrollment of women is continuous and is characterized by a relative high proportion of women born in the Netherlands with a high education compared with the general Dutch pregnant population. Data on current pregnancy, obstetric history, maternal lifestyle, health and medication use, delivery, and infant health are collected through web-based questionnaires completed by the participating women (three times during pregnancy and three times during the infant’s first year of life). If permission is given, the self-reported data can be complemented with information retrieved from Perined, the perinatal registry of the Netherlands, and from obstetric and medical records, and/or pharmacy records. Here, we provide detailed information on the design of the pREGnant, the Dutch Pregnancy Drug Register, as well as descriptive information on characteristics of the participants so far. Currently, steps are being taken to implement the register on a large scale in the Netherlands.

Uncontrolled maternal chronic respiratory diseases in pregnancy: A new potential risk factor suggested to be associated with anorectal malformations in offspring

BACKGROUND

Chronic respiratory diseases and use of antiasthmatic medication during pregnancy may both play a role in the etiology of congenital anorectal malformations (ARM). However, it is unclear, whether the medication use or the underlying condition would be responsible. Therefore, our aim was to unravel the role of maternal chronic respiratory diseases from that of antiasthmatic medication in the etiology of ARM.

METHODS

We obtained 412 ARM patients and 2,137 population-based controls from the Dutch AGORA data- and biobank. We used maternal questionnaires and follow-up telephone interviews to obtain information on chronic respiratory diseases, antiasthmatic medication use, and potential confounders. Multivariable logistic regression analyses were performed to estimate odds ratios (ORs) with 95% confidence intervals (95% CI).

RESULTS

We observed higher risk estimates among women with chronic respiratory diseases with and without medication use (1.4 [0.8-2.7] and 2.0 [0.8-5.0]), both in comparison to women without a chronic respiratory disease and without medication use. Furthermore, increased ORs of ARM were found for women using rescue medication (2.4 [0.8-7.3]) or a combination of maintenance and rescue medication (2.5 [0.9-6.7]). In addition, increased risk estimates were observed for women having nonallergic triggers (2.5 [1.0-6.3]) or experiencing exacerbations during the periconceptional period (3.5 [1.4-8.6]).

CONCLUSIONS

Although the 95% CIs of most associations include the null value, the risk estimates all point towards an association between uncontrolled chronic respiratory disease, instead of antiasthmatic medication use, with ARM in offspring. Further in-depth studies towards mechanisms of this newly identified risk factor are warranted.

Depression and anxiety during pregnancy: The influence of maternal characteristics

BACKGROUND

Depression and anxiety during pregnancy are associated with adverse health outcomes for both mother and child. This study aims to investigate the occurrence of symptoms of depression and anxiety in early and late pregnancy, the longitudinal changes from early to late pregnancy, and factors associated with symptoms of depression and anxiety in pregnant women in the Netherlands.

METHODS

We studied 2897 women participating in the PRegnancy and Infant DEvelopment (PRIDE) Study. To assess symptoms of depression and anxiety, web-based questionnaires including the Hospital Anxiety and Depression Scale (HADS) and multiple questions on maternal characteristics were completed in early and late pregnancy. Cross-sectional and longitudinal multivariable linear regression analyses were conducted.

RESULTS

The depressive symptoms in our population increased, with a prevalence of probable depression from 5.4% in early pregnancy to 10.0% in late pregnancy (P < .001), whereas the anxiety symptoms decreased, with a prevalence of probable anxiety from 17.9% to 14.2% (P < .001). Characteristics associated with depressive or anxiety symptoms included low level of education, multiparity, a history of depression, severe nausea, extreme fatigue, lack of physical exercise, and negative life events. Being non-Dutch, not living with a partner, and having an unplanned pregnancy or a long time to pregnancy were associated with the depressive and/or anxiety symptoms in early pregnancy only.

DISCUSSION

Symptoms of depression and anxiety are common in both early and late pregnancy. Screening for risk factors in early pregnancy is important, since prenatal depression and anxiety may be related to adverse maternal and child health outcomes.

The relationship between asthma and depression in a community-based sample

OBJECTIVE

Asthma is an increasingly prevalent disease that is associated with substantial physical and financial burdens. Additionally, asthma is linked to psychiatric disorders. This study examines the relationship between asthma diagnosis, current depressive symptoms, and lifetime psychiatric disorder history in a large, community-based sample.

METHODS

We analyzed data from 2168 participants in the Dallas Heart Study, a large, diverse, community-based sample of people designed to be representative of the Dallas County population. Logistic regressions analyzing the relationship between asthma diagnosis and history of a psychiatric disorder, as well as between asthma diagnosis and the Quick Inventory of Depressive Symptomatology (QIDS) scores were performed, controlling for demographic data.

RESULTS

13.4% of the sample had an asthma diagnosis. Asthma diagnosis was significantly associated with a history of nervous, emotional, or mental health disorder diagnosis [OR 1.810 (95% CI 1.280-2.559) p = 0.001], and with QIDS scores consistent with moderate or greater current depressive symptom severity [OR 1.586 (95%CI 1.106-2.274) p = 0.012]. The relationships were not moderated by age, gender, race, smoking status, or Body Mass Index.

CONCLUSIONS

A diagnosis of asthma may be associated with current clinically significant levels of depressive symptoms and a lifetime psychiatric disorder. The current report adds to the existing literature in this area by assessing both current and lifetime symptoms and by using a large and diverse population. The findings highlight the clinical importance of considering the possibility of psychiatric illness in asthma patients and suggest further research in this area is needed.

Gastrointestinal symptom improvement from fiber, STW 5, peppermint oil, and probiotics use-Results from an online survey

OBJECTIVES

Several common supplements are used by a significant number of patients affected by gastrointestinal (GI) disorders to improve symptoms and quality of life. We investigated the impact of GI symptom improvement with the use of fiber, STW 5, probiotics, and peppermint oil in relation to overall GI pain and quality of life via an online survey.

DESIGN

We used a cross-sectional, descriptive, correlation design. A Qualtrics online survey was utilized to collect data from January to June 2013 through various websites. Areas evaluated included participant demographics, use of supplements, and gastrointestinal symptom severity.

RESULTS

The rate of supplement use among patients with GI disorders was high (90% in past year) and consultation with healthcare providers was reported by 80%. Participants who completed the survey (n = 68) reported a strong correlation between GI symptom severity and overall quality of life (r² = 0.8682, p < 0.001). The use of fiber improved GI symptom severity while both STW 5 and probiotics were linked to specific improvements.

CONCLUSIONS

Persons with chronic GI disorders often choose the complementary use of common supplements to mitigate GI symptoms and consult with their healthcare providers frequently. The use of STW 5 and probiotics specifically is linked to overall reduction in GI symptoms and improvement of quality of life.

Prenatal Exposure to Acetaminophen and Risk for Attention Deficit Hyperactivity Disorder and Autistic Spectrum Disorder: A Systematic Review, Meta-Analysis, and Meta-Regression Analysis of Cohort Studies

Acetaminophen is the analgesic and antipyretic most commonly used during pregnancy. Evidence of neurodisruptive properties is accumulating. Therefore, we sought to evaluate the risk for attention deficit hyperactivity disorder (ADHD) and autistic spectrum disorder (ASD) in the offspring of women exposed to acetaminophen during pregnancy. We searched MEDLINE, Embase, and Cochrane databases for relevant studies up to January 2017. Data were independently extracted and assessed by 2 researchers. Seven eligible retrospective cohorts included 132,738 mother-child pairs, with follow-up periods ranging from 3 to 11 years. The pooled risk ratio for ADHD was 1.34 (95% confidence interval (CI): 1.21, 1.47; I2 = 72%); for ASD, the risk ratio was 1.19 (95% CI: 1.14, 1.25; I2 = 14%), and for hyperactivity symptoms, it was 1.24 (95% CI: 1.04, 1.43; I2 = 93%). In meta-regression analysis, the association between exposure and ADHD increased with the child's age upon follow-up (β = 0.03, 95% CI: 0.00, 0.07) and with the mean duration of exposure (β = 0.00, 95% CI: 0.00, 0.01). The available data is of observational nature only. Studies differed widely in exposure and outcome assessment. Acetaminophen use during pregnancy is associated with an increased risk for ADHD, ASD, and hyperactivity symptoms. These findings are concerning; however, results should be interpreted with caution given that the available evidence consists of observational studies and is susceptible to several potential sources of bias.

Knowledge, Attitudes, and Practices Regarding Zika: Paper- and Internet-Based Survey in Zhejiang, China

BACKGROUND

As public access to the Internet increases, many health workers prefer to carry out health education online, reducing the use of traditional community-based health education methods. Since March 2016, four Zika cases have been confirmed in Zhejiang, China. Rapid assessment of people's knowledge, attitudes, and practices (KAP) regarding Zika is crucial to its prevention and control. Web-based surveys to assess public KAP may be a growing trend; however, we had little experience with this method.

OBJECTIVES

The aim of this study was to explore KAP regarding Zika in residents of Zhejiang using both traditional paper- and innovative Internet-based investigations.

METHODS

A questionnaire was designed by Zhejiang Provincial Center for Disease Control and Prevention. A paper-based version of the survey was used in a cross-sectional community study following multistage cluster random sampling, and an Internet-based survey was promoted through a local health education site. Data were interpreted via univariate and multivariate analyses.

RESULTS

A total of 447 community residents participated in the paper-based survey, with a response rate of 89.4% (447/500), and 621 eligible Internet users participated in the Internet-based survey, with a response rate of 36.92% (621/1682). Age, education level, and occupation differed significantly between participants in the paper- and Internet-based surveys. Participants completing the Internet-based survey were much younger (χ²₂=144.7, P<.001) and had a higher level of education (χ²₂=423.5, P<.001) than those completing the paper-based survey. Among participants completing the paper-based survey, there were more farmers, housewives, and unemployed people (χ²₃=413.7, P<.001). Overall, 83.52% of participants (892/1068) knew the transmission route for Zika, 76.12% (813/1068) knew that pregnant women were at high risk of severe complications, 66.39% (709/1068) knew that contracting Zika during pregnancy could lead to newborn babies with microcephaly, and 98.88% (1056/1068) knew places where mosquitos could usually be found. After controlling for sociodemographic variables, participants completing the Internet-based survey were more likely to know the transmission route of Zika (odds ratio [OR]=5.0, 95% CI 3.0-8.0), the association between pregnant women with Zika and newborn babies with microcephaly (OR 2.1, 95% CI 1.4-3.0), and that pregnant women were at high risk for Zika (OR 5.5, 95% CI 3.5-8.4) than those completing the paper-based survey. They were less likely to worry about contracting Zika (OR 0.6, 95% CI 0.4-0.9) and more likely to actively seek information about Zika than participants completing the paper-based survey (OR 3.3, 95% CI 2.0-5.6).

CONCLUSIONS

Participants completing the Internet-based survey had a higher level of basic knowledge and more positive attitudes and behaviors than participants completing the paper-based survey. In addition to providing Web-based health information, the government should ensure sufficient access to health information for the elderly and less educated people in the community to improve health equity.

Hippocampal volume in patients with asthma: Results from the Dallas Heart Study

INTRODUCTION

Asthma is associated with an increased risk of mild cognitive impairment and dementia. Depression and oral corticosteroid use are associated with atrophy of the hippocampus and are common in asthma. However, minimal neuroimaging data are available in asthma patients.

METHODS

We conducted a retrospective analysis of 1,287 adult participants from the Dallas Heart Study, an epidemiological sample of Dallas County residents. Study outcome variables were hippocampal volumes measured by FreeSurfer. ANOVA was used to examine a gender difference in hippocampal volumes. General Linear Models (GLM) were conducted to examine asthma diagnosis association with hippocampal volumes.

RESULTS

The prevalence rate of asthma among our study sample was 10.8% with 9.6% in males and 11.7% in females. After controlling for demographic characteristics, participants with asthma had significantly smaller total, right, and left hippocampal volumes than those without asthma. The association of asthma with smaller hippocampal volume was significant among males but not among females.

CONCLUSION

Hippocampal volume in a large and diverse sample of adults was significantly smaller in people with asthma as compared to those without asthma. These findings suggest that asthma may be associated with structural brain differences. Thus, medical illnesses without obvious direct neurodegenerative or even vascular involvement can be associated with brain changes. Because the hippocampus is a brain region involved in memory formation, these findings may have implications for treatment adherence that could have important implications for asthma treatment. Study limitations are the reliance on a self-reported asthma diagnosis and lack of additional asthma clinical information.