Maternal Deaths Using Coroner's Data: A Latent Class Analysis

OBJECTIVE

Knowledge regarding the antecedent clinical and social factors associated with maternal death around the time of pregnancy is limited. This study identified distinct subgroups of maternal deaths using population-based coroner's data, and that may inform ongoing preventative initiatives.

METHODS

A detailed review of coroner's death files was performed for all of Ontario, Canada, where there is a single reporting mechanism for maternal deaths. Deaths in pregnancy, or within 365 days thereafter, were identified within the Office of the Chief Coroner for Ontario database, 2004-2020. Variables related to the social and clinical circumstances surrounding the deaths were abstracted in a standardized manner from each death file, including demographics, forensic information, nature and cause of death, and antecedent health and health care factors. These variables were then entered into a latent class analysis (LCA) to identify distinct types of deaths.

RESULTS

Among 273 deaths identified in the study period, LCA optimally identified three distinct subgroups, namely, (1) in-hospital deaths arising during birth or soon thereafter (52.7% of the sample); (2) accidents and unforeseen obstetric complications also resulting in infant demise (26.3%); and (3) out-of-hospital suicides occurring postpartum (21.0%). Physical injury (22.0%) was the leading cause of death, followed by hemorrhage (16.8%) and overdose (13.3%).

CONCLUSION

Peri-pregnancy maternal deaths can be classified into three distinct sub-types, with somewhat differing causes. These findings may enhance clinical and policy development aimed at reducing pregnancy mortality.

The impact of funding models on the integration of Ontario midwives: a qualitative study

BACKGROUND

Nearly 30 years post legalisation and introduction, midwifery is still not optimally integrated within the health system of Canada's largest province, Ontario. Funding models have been identified as one of the main barriers.

METHODS

Using a constructivist perspective, we conducted a qualitative descriptive study to examine how antepartum, intrapartum, and postpartum funding arrangements in Ontario impact midwifery integration. We conceptualized optimal 'integration' as circumstances in which midwives' knowledge, skills, and model of care are broadly respected and fully utilized, interprofessional collaboration and referral support the best possible care for patients, and midwives feel a sense of belonging within hospitals and the greater health system. We collected data through semi-structured telephone interviews with midwives, obstetricians, family physicians, and nurses. The data was examined using thematic analysis.

RESULTS

We interviewed 20 participants, including 5 obstetricians, 5 family physicians, 5 midwives, 4 nurses, and 1 policy expert. We found that while course-of-care-based midwifery funding is perceived to support high levels of midwifery client satisfaction and excellent clinical outcomes, it lacks flexibility. This limits opportunities for interprofessional collaboration and for midwives to use their knowledge and skills to respond to health system gaps. The physician fee-for-service funding model creates competition for births, has unintended consequences that limit midwives' scope and access to hospital privileges, and fails to appropriately compensate physician consultants, particularly as midwifery volumes grow. Siloing of midwifery funding from hospital funding further restricts innovative contributions from midwives to respond to community healthcare needs.

CONCLUSIONS

Significant policy changes, such as adequate remuneration for consultants, possibly including salary-based physician funding; flexibility to compensate midwives for care beyond the existing course of care model; and a clearly articulated health human resource plan for sexual and reproductive care are needed to improve midwifery integration.

Pregnancy, fetal, and neonatal outcomes after a first booster dose of covid-19 vaccine during pregnancy in Ontario, Canada: population based, retrospective cohort study

Objective

To assess risk of adverse pregnancy, fetal, and neonatal outcomes after a third dose (first booster dose) of covid-19 vaccine during pregnancy among individuals who had completed both doses of primary covid-19 vaccine series before pregnancy.

Design

Population based, retrospective cohort study.

Setting

Ontario, Canada, from 20 December 2021 to 31 August 2022.

Participants

Individuals were included if they were pregnant with an expected date of delivery from 20 December 2021 (start date of third dose eligibility for everyone ≥18 years) to 31 August 2022, who had completed the two doses of primary covid-19 messenger RNA vaccine series before pregnancy, and became eligible for a third dose (≥six months since dose two) before the end of pregnancy.

Main outcome measures

Pregnancy outcomes included hypertensive disorders of pregnancy, placental abruption, caesarean delivery, chorioamnionitis, and postpartum hemorrhage. Fetal and neonatal outcomes included stillbirth, preterm birth, admission to neonatal intensive care unit for >24 h, newborn 5 min Apgar score <7, and small-for-gestational age infant (<10th percentile). We estimated hazard ratios and 95% confidence intervals for study outcomes, treating dose three as a time varying exposure and adjusting for confounding using inverse probability weighting.

Results

Among 32 689 births, 18 491 (56.6%) were born to individuals who received a third covid-19 dose during pregnancy. Compared with eligible individuals who did not receive a third dose during pregnancy, no increased risks were associated with receiving a third covid-19 vaccine dose during pregnancy for placental abruption (adjusted hazard ratio 0.84 (95% confidence interval 0.70 to 1.02)), chorioamnionitis (0.67 (0.49 to 0.90)), postpartum haemorrhage (1.01 (0.89 to 1.16)), caesarean delivery (0.90 (0.87 to 0.94)), stillbirth (0.56 (0.39 to 0.81)), preterm birth (0.91 (0.84 to 0.99)), neonatal intensive care unit admission (0.96 (0.90 to 1.03)), 5 min Apgar score<7 (0.96 (0.82 to 1.14)), or small-for-gestational age infant (0.86 (0.79 to 0.93)).

Conclusion

Receipt of a third covid-19 vaccine dose during pregnancy was not associated with an increased risk of adverse pregnancy, fetal, or neonatal outcomes. These findings can help to inform evidence based decision making about the risks and benefits of covid-19 booster doses during pregnancy.

Temporal trends and determinants of COVID-19 vaccine series initiation after recent pregnancy

During the rapid deployment of COVID-19 vaccines in 2021, safety concerns may have led some pregnant individuals to postpone vaccination until after giving birth. This study aimed to describe temporal patterns and factors associated with COVID-19 vaccine series initiation after recent pregnancy in Ontario, Canada. Using the provincial birth registry linked with the COVID-19 vaccine database, we identified all individuals who gave birth between January 1 and December 31, 2021, and had not yet been vaccinated by the end of pregnancy, and followed them to June 30, 2022 (follow-up ranged from 6 to 18 months). We used cumulative incidence curves to describe COVID-19 vaccine initiation after pregnancy and assessed associations with sociodemographic, pregnancy-related, and health behavioral factors using Cox proportional hazards regression to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI). Among 137,198 individuals who gave birth in 2021, 87,376 (63.7%) remained unvaccinated at the end of pregnancy; of these, 65.0% initiated COVID-19 vaccination by June 30, 2022. Lower maternal age (<25 vs. 30-34 y aHR: 0.73, 95%CI: 0.70-0.77), smoking during pregnancy (vs. nonsmoking aHR: 0.68, 95%CI: 0.65-0.72), lower neighborhood income (lowest quintile vs. highest aHR: 0.79, 95%CI: 0.76-0.83), higher material deprivation (highest quintile vs. lowest aHR: 0.74, 95%CI: 0.70-0.79), and exclusive breastfeeding (vs. other feeding aHR: 0.81, 95%CI: 0.79-0.84) were associated with lower likelihood of vaccine initiation. Among unvaccinated individuals who gave birth in 2021, COVID-19 vaccine initiation after pregnancy reached 65% by June 30, 2022, suggesting persistent issues with vaccine hesitancy and/or access to vaccination in this population.

Temporal trends and determinants of COVID-19 vaccine coverage and series initiation during pregnancy in Ontario, Canada, December 2020 to December 2021: A population-based retrospective cohort study

BACKGROUND

Population-based COVID-19 vaccine coverage estimates among pregnant individuals are limited. We assessed temporal patterns in vaccine coverage (≥1 dose before or during pregnancy) and evaluated factors associated with vaccine series initiation (receiving dose 1 during pregnancy) in Ontario, Canada.

METHODS

We linked the provincial birth registry with COVID-19 vaccination records from December 14, 2020 to December 31, 2021 and assessed coverage rates among all pregnant individuals by month, age, and neighborhood sociodemographic characteristics. Among individuals who gave birth since April 2021-when pregnant people were prioritized for vaccination-we assessed associations between sociodemographic, behavioral, and pregnancy-related factors with vaccine series initiation using multivariable regression to estimate adjusted risk ratios (aRR) and risk differences (aRD) with 95% confidence intervals (CI).

RESULTS

Among 221,190 pregnant individuals, vaccine coverage increased to 71.2% by December 2021. Gaps in coverage across categories of age and sociodemographic characteristics decreased over time, but did not disappear. Lower vaccine series initiation was associated with lower age (<25 vs. 30-34 years: aRR 0.53, 95%CI 0.51-0.56), smoking (vs. non-smoking: 0.64, 0.61-0.67), no first trimester prenatal care visit (vs. visit: 0.80, 0.77-0.84), and residing in neighborhoods with the lowest income (vs. highest: 0.69, 0.67-0.71). Vaccine series initiation was marginally higher among individuals with pre-existing medical conditions (vs. no conditions: 1.07, 1.04-1.10).

CONCLUSIONS

COVID-19 vaccine coverage among pregnant individuals remained lower than in the general population, and there was lower vaccine initiation by multiple characteristics.

Risk of preterm birth, small for gestational age at birth, and stillbirth after covid-19 vaccination during pregnancy: population based retrospective cohort study

OBJECTIVE

To assess the risk of preterm birth, small for gestational age at birth, and stillbirth after covid-19 vaccination during pregnancy.

DESIGN

Population based retrospective cohort study.

SETTING

Ontario, Canada, 1 May to 31 December 2021.

PARTICIPANTS

All liveborn and stillborn infants from pregnancies conceived at least 42 weeks before the end of the study period and with gestational age ≥20 weeks or birth weight ≥500 g.

MAIN OUTCOME MEASURES

Using Cox regression, hazard ratios and 95% confidence intervals were estimated for preterm birth before 37 weeks (overall and spontaneous preterm birth), very preterm birth (<32 weeks), small for gestational age at birth (<10th centile), and stillbirth. Vaccination against covid-19 was treated as a time varying exposure in the outcome specific risk window, and propensity score weighting was used to adjust hazard ratios for potential confounding.

RESULTS

Among 85 162 births, 43 099 (50.6%) occurred in individuals who received one dose or more of a covid-19 vaccine during pregnancy-42 979 (99.7%) received an mRNA vaccine. Vaccination during pregnancy was not associated with any increased risk of overall preterm birth (6.5% among vaccinated v 6.9% among unvaccinated; adjusted hazard ratio 1.02, 95% confidence interval 0.96 to 1.08), spontaneous preterm birth (3.7% v 4.4%; 0.96, 0.90 to 1.03), or very preterm birth (0.59% v 0.89%; 0.80, 0.67 to 0.95). No increase was found in risk of small for gestational age at birth (9.1% v 9.2%; 0.98, 0.93 to 1.03) or stillbirth (0.25% v 0.44%; 0.65, 0.51 to 0.84). Findings were similar by trimester of vaccination, mRNA vaccine product, and number of doses received during pregnancy.

CONCLUSION

The findings suggest that vaccination against covid-19 during pregnancy is not associated with a higher risk of preterm birth, small for gestational age at birth, or stillbirth.

Association of SARS-CoV-2 Infection During Pregnancy With Maternal and Perinatal Outcomes

IMPORTANCE

There are limited high-quality, population-level data about the effect of SARS-CoV-2 infection on pregnancy using contemporaneous comparator cohorts.

OBJECTIVES

To describe maternal and perinatal outcomes associated with SARS-CoV-2 infection in pregnancy and to assess variables associated with severe disease in the pregnant population.

DESIGN, SETTING, AND PARTICIPANTS

CANCOVID-Preg is an observational surveillance program for SARS-CoV-2-affected pregnancies in Canada. This analysis presents exploratory, population-level data from 6 Canadian provinces for the period of March 1, 2020, to October 31, 2021. A total of 6012 pregnant persons with a positive SARS-CoV-2 polymerase chain reaction test result at any time in pregnancy (primarily due to symptomatic presentation) were included and compared with 2 contemporaneous groups including age-matched female individuals with SARS-CoV-2 and unaffected pregnant persons from the pandemic time period.

EXPOSURE

SARS-CoV-2 infection during pregnancy. Incident infections in pregnancy were reported to CANCOVID-Preg by participating provinces/territories.

MAIN OUTCOMES AND MEASURES

Maternal and perinatal outcomes associated with SARS-CoV-2 infection as well as risk factors for severe disease (ie, disease requiring hospitalization, admission to an intensive care unit/critical care unit, and/or oxygen therapy).

RESULTS

Among 6012 pregnant individuals with SARS-CoV-2 in Canada (median age, 31 [IQR, 28-35] years), the greatest proportion of cases were diagnosed at 28 to 37 weeks' gestation (35.7%). Non-White individuals were disproportionately represented. Being pregnant was associated with a significantly increased risk of SARS-CoV-2-related hospitalization compared with SARS-CoV-2 cases among all women aged 20 to 49 years in the general population of Canada (7.75% vs 2.93%; relative risk, 2.65 [95% CI, 2.41-2.88]) as well as an increased risk of intensive care unit/critical care unit admission (2.01% vs 0.37%; relative risk, 5.46 [95% CI, 4.50-6.53]). Increasing age, preexisting hypertension, and greater gestational age at diagnosis were significantly associated with worse maternal outcomes. The risk of preterm birth was significantly elevated among SARS-CoV-2-affected pregnancies (11.05% vs 6.76%; relative risk, 1.63 [95% CI, 1.52-1.76]), even in cases of milder disease not requiring hospitalization, compared with unaffected pregnancies during the same time period.

CONCLUSIONS AND RELEVANCE

In this exploratory surveillance study conducted in Canada from March 2020 to October 2021, SARS-CoV-2 infection during pregnancy was significantly associated with increased risk of adverse maternal outcomes and preterm birth.

Association of COVID-19 Vaccination in Pregnancy With Adverse Peripartum Outcomes

Importance

There is limited comparative epidemiological evidence on outcomes associated with COVID-19 vaccination during pregnancy; monitoring pregnancy outcomes in large populations is required.

Objective

To evaluate peripartum outcomes following COVID-19 vaccination during pregnancy.

Design, Setting, and Participants

Population-based retrospective cohort study in Ontario, Canada, using a birth registry linked with the provincial COVID-19 immunization database. All births between December 14, 2020, and September 30, 2021, were included.

Exposures

COVID-19 vaccination during pregnancy, COVID-19 vaccination after pregnancy, and no vaccination.

Main Outcomes and Measures

Postpartum hemorrhage, chorioamnionitis, cesarean delivery (overall and emergency cesarean delivery), admission to neonatal intensive care unit (NICU), and low newborn 5-minute Apgar score (<7). Linear and robust Poisson regression was used to generate adjusted risk differences (aRDs) and risk ratios (aRRs), respectively, comparing cumulative incidence of outcomes in those who received COVID-19 vaccination during pregnancy with those vaccinated after pregnancy and those with no record of COVID-19 vaccination at any point. Inverse probability of treatment weights were used to adjust for confounding.

Results

Among 97 590 individuals (mean [SD] age, 31.9 [4.9] years), 22 660 (23%) received at least 1 dose of COVID-19 vaccine during pregnancy (63.6% received dose 1 in the third trimester; 99.8% received an mRNA vaccine). Comparing those vaccinated during vs after pregnancy (n = 44 815), there were no significantly increased risks of postpartum hemorrhage (incidence: 3.0% vs 3.0%; aRD, -0.28 per 100 individuals [95% CI, -0.59 to 0.03]; aRR, 0.91 [95% CI, 0.82-1.02]), chorioamnionitis (0.5% vs 0.5%; aRD, -0.04 per 100 individuals [95% CI, -0.17 to 0.09]; aRR, 0.92 [95% CI, 0.70-1.21]), cesarean delivery (30.8% vs 32.2%; aRD, -2.73 per 100 individuals [95% CI, -3.59 to -1.88]; aRR, 0.92 [95% CI, 0.89-0.95]), NICU admission (11.0% vs 13.3%; aRD, -1.89 per 100 newborns [95% CI, -2.49 to -1.30]; aRR, 0.85 [95% CI, 0.80-0.90]), or low Apgar score (1.8% vs 2.0%; aRD, -0.31 per 100 newborns [95% CI, -0.56 to -0.06]; aRR, 0.84 [95% CI, 0.73-0.97]). Findings were qualitatively similar when compared with individuals who did not receive COVID-19 vaccination at any point (n = 30 115).

Conclusions and Relevance

In this population-based cohort study in Ontario, Canada, COVID-19 vaccination during pregnancy, compared with vaccination after pregnancy and with no vaccination, was not significantly associated with increased risk of adverse peripartum outcomes. Study interpretation should consider that the vaccinations received during pregnancy were primarily mRNA vaccines administered in the second and third trimester.

Maternal-Newborn Health System Changes and Outcomes in Ontario Canada during Wave 1 of the COVID-19 Pandemic - A Retrospective Study

OBJECTIVE

To determine the population-level impact of COVID-19 pandemic-related obstetric practice changes on maternal and newborn outcomes.

METHODS

Segmented regression analysis examined changes that occurred 240 weeks pre-pandemic through the first 32 weeks of the pandemic using data from Ontario's Better Outcomes Registry & Network. Outcomes included birth location, length of stay, labour analgesia, mode of delivery, preterm birth, and stillbirth. Immediate and gradual effects were modelled with terms representing changes in intercepts and slopes, corresponding to the start of the pandemic.

RESULTS

There were 799 893 eligible pregnant individuals included in the analysis; 705 767 delivered in the pre-pandemic period and 94,126 during the pandemic wave 1 period. Significant immediate decreases were observed for hospital births (relative risk [RR] 0.99; 95% CI 0.98-0.99), length of stay (median change -3.29 h; 95% CI -3.81 to -2.77), use of nitrous oxide (RR 0.11; 95% CI 0.09-0.13) and general anesthesia (RR 0.69; 95% CI 0.58- 0.81), and trial of labour after cesarean (RR 0.89; 95% CI 0.83-0.96). Conversely, there were significant immediate increases in home births (RR 1.35; 95% CI 1.21-1.51), and use of epidural (RR 1.02; 95% CI 1.01-1.04) and regional anesthesia (RR 1.01; 95% CI 1.01-1.02). There were no significant immediate changes for any other outcomes, including preterm birth (RR 0.99; 95% CI 0.93-1.05) and stillbirth (RR 1.11; 95% CI 0.87-1.42).

CONCLUSION

Provincial health system changes implemented at the start of the pandemic resulted in immediate clinical practice changes but no significant increases in adverse outcomes.

Association of Maternal Influenza Vaccination During Pregnancy With Early Childhood Health Outcomes

IMPORTANCE

Seasonal influenza vaccination in pregnancy can reduce influenza illness among pregnant women and newborns. Evidence is limited on whether seasonal influenza vaccination in pregnancy is associated with adverse childhood health outcomes.

OBJECTIVE

To assess the association between maternal influenza vaccination during pregnancy and early childhood health outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study, using a birth registry linked with health administrative data. All live births in Nova Scotia, Canada, between October 1, 2010, and March 31, 2014, were included, with follow-up until March 31, 2016. Adjusted hazard ratios (HRs) and incidence rate ratios (IRRs) with 95% confidence intervals were estimated while controlling for maternal medical history and other potential confounders using inverse probability of treatment weighting.

EXPOSURES

Seasonal influenza vaccination during pregnancy.

MAIN OUTCOMES AND MEASURES

Childhood outcomes studied were immune-related (eg, asthma, infections), non-immune-related (eg, neoplasms, sensory impairment), and nonspecific (eg, urgent or inpatient health care utilization), measured from emergency department and hospitalization databases.

RESULTS

Among 28 255 children (49% female, 92% born at ≥37 weeks' gestation), 10 227 (36.2%) were born to women who received seasonal influenza vaccination during pregnancy. During a mean follow-up of 3.6 years, there was no significant association between maternal influenza vaccination and childhood asthma (incidence rate, 3.0 vs 2.5 per 1000 person-years; difference, 0.53 per 1000 person-years [95% CI, -0.15 to 1.21]; adjusted HR, 1.22 [95% CI, 0.94 to 1.59]), neoplasms (0.32 vs 0.26 per 1000 person-years; difference, 0.06 per 1000 person-years [95% CI, -0.16 to 0.28]; adjusted HR, 1.26 [95% CI, 0.57 to 2.78]), or sensory impairment (0.80 vs 0.97 per 1000 person-years; difference, -0.17 per 1000 person-years [95% CI, -0.54 to 0.21]; adjusted HR, 0.82 [95% CI, 0.49 to 1.37]). Maternal influenza vaccination in pregnancy was not significantly associated with infections in early childhood (incidence rate, 184.6 vs 179.1 per 1000 person-years; difference, 5.44 per 1000 person-years [95% CI, 0.01 to 10.9]; adjusted IRR, 1.07 [95% CI, 0.99 to 1.15]) or with urgent and inpatient health services utilization (511.7 vs 477.8 per 1000 person-years; difference, 33.9 per 1000 person-years [95% CI, 24.9 to 42.9]; adjusted IRR, 1.05 [95% CI, 0.99 to 1.16]).

CONCLUSIONS AND RELEVANCE

In this population-based cohort study with mean follow-up duration of 3.6 years, maternal influenza vaccination during pregnancy was not significantly associated with an increased risk of adverse early childhood health outcomes.

Client Experience with the Ontario Birth Center Demonstration Project

INTRODUCTION

In 2014, 2 new freestanding midwifery-led birth centers opened in Ontario, Canada. As one part of a larger mixed-methods evaluation of the first year of operations of the centers, our primary objective was to compare the experiences of women receiving midwifery care who intended to give birth at the new birth centers with those intending to give birth at home or in hospital.

METHODS

We conducted a cross-sectional survey of women cared for by midwives with admitting privileges at one of the 2 birth centers. Consenting women received the survey 3 to 6 weeks after their due date. We stratified the analysis by intended place of birth at the beginning of labor, regardless of where the actual birth occurred. One composite indicator was created (Composite Satisfaction Score, out of 20), and statistical significance (P < .05) was assessed using one-way analysis of variance. Responses to the open-ended questions were reviewed and grouped into broader categories.

RESULTS

In total, 382 women completed the survey (response rate 54.6%). Half intended to give birth at a birth center (n = 191). There was a significant difference on the Composite Satisfaction Scores between the birth center (19.4), home (19.5), and hospital (18.9) groups (P < .001). Among women who intended to give birth in a birth center, scores were higher in the women admitted to the birth center compared with those who were not (P = .037). Overall, women giving birth at a birth center were satisfied with the learners present at their birth, the accessibility of the centers, and the physical amenities, and they had suggestions for minor improvements.

DISCUSSION

We found positive experiences and high satisfaction among women receiving midwifery care, regardless of intended place of birth. Women admitted to the birth centers had positive experiences with these new centers; however, future research should be planned to reassess and further understand women's experiences.

Neonatal outcome by planned mode of delivery in women with a body mass index of 35 or more: a retrospective cohort study

OBJECTIVE

To compare neonatal outcomes of women with a body mass index (BMI) of ≥35 kg/m² who underwent a trial of labour with those of women who underwent a planned primary caesarean section (CS).

DESIGN

A retrospective cohort study of births between April 2012 and March 2014.

SETTING

A provincial database: Better Outcomes Registry & Network (BORN) Ontario, Canada.

POPULATION

A cohort of 8752 women with a BMI of ≥35 kg/m² who had a singleton birth at 38-42 weeks of gestation.

METHODS

Neonatal outcomes were compared between women who underwent a trial of labour (with either a successful vaginal birth or intrapartum CS) and those who underwent a planned CS.

MAIN OUTCOME MEASURE

A composite of any of the following outcomes: intrapartum neonatal death, neonatal intensive care unit admission, 5-minute Apgar score of <7 or umbilical artery pH of <7.1.

RESULTS

During the study period, 8433 (96.4%) women had a trial of labour and 319 (3.6%) had a planned CS. Intrapartum CS was performed in 1644 (19.5%) cases. There was no association between planned mode of delivery and the primary outcome (aOR 0.80, 95% CI 0.59-1.07). The primary outcome was lower among women who had a successful trial of labour (aOR 0.67, 95% CI 0.50-0.91) and was higher among women who had a failed trial of labour (aOR 1.74, 95% CI 1.21-2.48), compared with women who underwent a planned CS.

CONCLUSIONS

In women with a BMI of ≥35 kg/m² at a gestational age of 38-42 weeks, neonatal outcomes are comparable between planned vaginal delivery and planned CS, although a failed trial of labour is at risk of adverse neonatal outcome.

TWEETABLE ABSTRACT

Neonatal outcomes are not affected by planned mode of delivery in women who are obese, with a BMI of ≥35 kg/m² .

CARTR Plus: the creation of an ART registry in Canada

STUDY QUESTION

What is the status of fertility treatment and birth outcomes documented over the first 6 years of the Canadian Assisted Reproductive Technologies Register (CARTR) Plus registry?

SUMMARY ANSWER

The CARTR Plus registry is a robust database containing comprehensive Canadian fertility treatment data to assist with providing evidence-based rationale for clinical practice change.

WHAT IS KNOWN ALREADY

The rate of infertility is increasing globally and having data on fertility treatment cycles and outcomes at a population level is important for accurately documenting and effecting changes in clinical practice.

STUDY DESIGN, SIZE, DURATION

This is a descriptive manuscript of 183 739 fertility treatment cycles from 36 Canadian clinics over 6 years from the CARTR Plus registry.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Canadian ART treatment cycles from 2013 through 2018 were included. This manuscript described trends in type of fertility treatment cycles, pregnancy rates, multiple pregnancy rates, primary transfer rates and birth outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

Over the 6 years of the CARTR Plus registry, the number of treatment cycles performed ranged from less than 200 to greater than 1000 per clinic. Patient age and the underlying cause of infertility were two of the most variable characteristics across clinics. Similar clinical pregnancy rates were found among IVF and frozen embryo transfer (FET) cycles with own oocytes (38.9 and 39.7% per embryo transfer cycle, respectively). Fertility treatment cycles that used donor oocytes had a higher clinical pregnancy rate among IVF cycles compared with FET cycles (54.9 and 39.8% per embryo transfer cycle, respectively). The multiple pregnancy rate was 7.4% per ongoing clinical pregnancy in 2018, which reflected a decreasing trend across the study period. Between 2013 and 2017, there were 31 811 pregnancies that had live births from all ART treatment cycles, which corresponded to a live birth rate of 21.4% per cycle start and 89.1% of these pregnancies were singleton live births. The low multiple pregnancy rate and high singleton birth rate are associated with the increase in single embryo transfers.

LIMITATIONS, REASONS FOR CAUTION

There is potential for misclassification of data, which is present in all administrative health databases.

WIDER IMPLICATIONS OF THE FINDINGS

The CARTR Plus registry is a robust resource for ART data in Canada. It provides easily accessible aggregated data for Canadian fertility clinics, and it contains data that are internationally comparable.

STUDY FUNDING/COMPETING INTEREST(S)

There was no funding provided for this study. The authors have no competing interests to declare.

Associations of Assisted Reproductive Technology and Twin Pregnancy With Risk of Congenital Heart Defects

IMPORTANCE

The extent to which assisted reproductive technology is associated with increased risk of congenital heart defects independent of its known association with twinning remains uncertain.

OBJECTIVE

To assess the extent to which assisted pregnancy is associated with increased risk of congenital heart defects independent of its known association with twinning.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study linked records of congenital heart defect diagnoses with assisted reproductive technology cycles in 507 390 singleton or twin pregnancies (10 149 assisted pregnancies and 497 241 nonassisted pregnancies), including singleton and twin early pregnancy losses, stillbirths, and live births (follow-up to 1 year of age) in Ontario, Canada, between April 1, 2012, and October 31, 2015. Statistical analysis was performed from January 1, 2017, to September 9, 2019.

EXPOSURES

Assisted reproductive technology and its 2 subtypes: intracytoplasmic sperm injection and in vitro fertilization without intracytoplasmic sperm injection.

MAIN OUTCOMES AND MEASURES

The main outcome was congenital heart defects (prevalence and relative risk measured as odds ratios [ORs]). Mediation analysis was performed to assess the extent to which the association between assisted reproductive technology and congenital heart defects was mediated by twinning.

RESULTS

Of 507 390 mother-infant pairs with singleton or twin pregnancies evaluated, the prevalence of congenital heart defects in assisted pregnancies (223 [2.2%]) was higher than that in nonassisted pregnancies (6057 [1.2%]; crude OR, 1.82; 95% CI, 1.59-2.09). The strength of the association between assisted pregnancy and congenital heart defects decreased after adjusting for several risk factors simultaneously (adjusted OR, 1.70; 95% CI, 1.48-1.95). Further mediation analysis indicated that most of the association between assisted pregnancy and congenital heart defects was mediated by twinning (adjusted OR, 1.68; 95% CI, 1.44-1.92), and the natural direct association of assisted pregnancy with congenital heart defects among singleton pregnancies was 1.09 (95% CI, 0.93-1.25). Mediation of twinning accounted for 87.3% of the association.

CONCLUSIONS AND RELEVANCE

Our study results suggest that the association between assisted reproductive technology and congenital heart defects may be mediated by twinning.

A new record linkage for assessing infant mortality rates in Ontario, Canada

OBJECTIVE

Infant mortality statistics for Canada have routinely omitted Ontario-Canada's most populous province-as a high proportion of Vital Statistics infant death registrations could not be linked with their corresponding Vital Statistics live birth registrations. We assessed the feasibility of linking an alternative source of live birth information with infant death registrations.

METHODS

All infant deaths occurring before 365 days of age registered in Ontario's Vital Statistics in 2010-2011 were linked with birth records in the Canadian Institute for Health Information's hospitalization database. Crude birthweight-specific and gestational age-specific infant mortality rates were calculated, and rates examined according to maternal and infant characteristics.

RESULTS

Of 1311 infant death registrations, only 47 (3.6%) could not be linked to a hospital birth record. The overall crude infant mortality rate was 4.7 deaths per 1000 live births (95% CI, 4.4 to 4.9), the same as previously reported for the rest of Canada in 2011. Infant mortality was higher in women < 20 years (5.8 per 1000 live births) and ≥ 40 years (5.9 per 1000 live births), and lowest among those aged 25-29 years (3.9 per 1000 live births). Infant mortality was notably higher in the lowest (5.1 per 1000 live births) residential income quintile than the highest (3.4 per 1000 live births).

CONCLUSION

Use of birth hospitalization records resulted in near-complete linkage of all Vital Statistics infant death registrations. This approach could enhance the conduct of representative surveillance and research on infant mortality when direct linkage of live birth and infant death registrations is not achievable.

The Canadian Assisted Reproductive Technologies Register (CARTR) Plus database: a validation study

STUDY QUESTION

Are data accurately documented in the Canadian Assisted Reproductive Technologies Register (CARTR) Plus database?

SUMMARY ANSWER

Measures of validity were strong for the majority of variables evaluated while those with moderate agreement were FSH levels, oocyte origin and elective single embryo transfer.

WHAT IS KNOWN ALREADY

Health databases and registries are excellent sources of data. However, as these databases are typically not established for the primary purpose of performing research, they should be evaluated prior to utilization for research both to inform the study design and to determine the extent to which key study variables, such as patient characteristics or therapies provided, are accurately documented in the database. CARTR Plus is Canada's national register for collecting extensive information on IVF and corresponding pregnancy outcomes, and it has yet to be validated.

STUDY DESIGN SIZE DURATION

This study evaluating the data translation CARTR Plus database examined IVF cycles performed in 2015 using data directly from patient charts. Six clinics across Canada were recruited to participate, using a purposive sampling strategy. Fixed random sampling was employed to select 146 patient cycles at each clinic, representing unique patients. Only a single treatment cycle record from a unique patient at each clinic was considered during chart selection.

PARTICIPANTS/MATERIALS SETTING METHODS

Twenty-five data elements (patient characteristics, treatments and outcomes) were reabstracted from patient charts, which were declared the reference standard. Data were reabstracted by two independent auditors with relevant clinical knowledge after confirming inter-rater reliability. These data elements from the chart were then compared to those in CARTR Plus. To determine the validity of these variables, we calculated kappa coefficients, sensitivity, specificity, positive predictive value and negative predictive value with 95% CI for categorical variables and calculated median differences and intraclass correlation coefficients (ICC) for continuous variables.

MAIN RESULTS AND THE ROLE OF CHANCE

Six clinics agreed to participate in this study representing five Canadian provinces. The mean age of patients was 35.5 years, which was similar between the two data sources, resulting in a near perfect level of agreement (ICC = 0.99; 95% CI: 0.99, 0.99). The agreement for FSH was moderate, ICC = 0.68 (95% CI: 0.64, 0.72). There was nearly perfect agreement for cycle type, kappa = 0.99 (95% CI: 0.98, 1.00). Over 90% of the cycles in the reabstracted charts used autologous oocytes; however, data on oocyte source were missing for 13% of cycles in CARTR Plus, resulting in a moderate degree of agreement, kappa = 0.45 (95% CI, 0.37, 0.52). Embryo transfer and number of embryos transferred had nearly perfect agreement, with kappa coefficients greater than 0.90, whereas that for elective single or double embryo transfer was much lower (kappa = 0.55; 95% CI: 0.49, 0.61). Agreement was nearly perfect for pregnancy type, and number of fetal sacs and fetal hearts on ultrasound, all with kappa coefficients greater than 0.90.

LARGE-SCALE DATA

N/A.

LIMITATIONS REASONS FOR CAUTION

CARTR Plus contains over 200 variables, of which only 25 were assessed in this study. This foundational validation work should be extended to other CARTR Plus database variables in future studies.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides the first assessment of the quality of the data translation process of the CARTR Plus database, and we found very high quality for the majority of the variables that were analyzed. We identified key data points that are either too often lacking or inconsistent with chart data, indicating that changes in the data entry process may be required.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by Canadian Institutes of Health Research (CIHR) (Grant Number FDN-148438) and by the Canadian Fertility and Andrology Society Research Seed Grant (Grant Number: N/A). The authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

Not applicable.

Data accuracy in the Ontario birth Registry: a chart re-abstraction study

Background

Ontario’s birth Registry (BORN) was established in 2009 to collect, interpret, and share critical data about pregnancy, birth and the early childhood period to facilitate and improve the provision of healthcare. Since the use of routinely-collected health data has been prioritized internationally by governments and funding agencies to improve patient care, support health system planning, and facilitate epidemiological surveillance and research, high quality data is essential. The purpose of this study was to verify the accuracy of a selection of data elements that are entered in the Registry.

Methods

Data quality was assessed by comparing data re-abstracted from patient records to data entered into the Ontario birth Registry. A purposive sample of 10 hospitals representative of hospitals in Ontario based on level of care, birth volume and geography was selected and a random sample of 100 linked mother and newborn charts were audited for each site. Data for 29 data elements were compared to the corresponding data entered in the Ontario birth Registry using percent agreement, kappa statistics for categorical data elements and intra-class correlation coefficients (ICCs) for continuous data elements.

Results

Agreement ranged from 56.9 to 99.8%, but 76% of the data elements (22 of 29) had greater than 90% agreement. There was almost perfect (kappa 0.81–0.99) or substantial (kappa 0.61–0.80) agreement for 12 of the categorical elements. Six elements showed fair-to-moderate agreement (kappa <0.60). We found moderate-to-excellent agreement for four continuous data elements (ICC >0.50).

Conclusion

Overall, the data elements we evaluated in the birth Registry were found to have good agreement with data from the patients’ charts. Data elements that showed moderate kappa or low ICC require further investigation.

Measuring Maternal Mortality in Canada: An Update on the Establishment of a Confidential Enquiry System for Preventing Maternal Deaths #savingmoms #savingbabies

A reduction in maternal mortality has traditionally been used as a critical measure of progress in improving maternal health, and the maternal mortality ratio is one of the main indicators of a country's status in the area. In Canada, maternal mortality is infrequent yet devastating. In many cases, there were no interventions that could have saved the mother's life, but in others, there were opportunities for prevention. There is absolute consensus that the upper limit for a preventable maternal death is zero. The World Health Organization's 2010 report indicated a rise in Canada's maternal mortality and prompted the Society of Obstetricians and Gynaecologists of Canada to work with partners to review national maternal mortality surveillance. Since then, efforts have begun and stalled. We are now in the fortunate position to work with experts and provincial leaders to implement a national system of confidential enquiry into maternal deaths and severe maternal morbidity in Canada. Canada's existing data do not tell the true story of maternal deaths; we cannot learn from each death and its circumstance to identify measures for prevention in the future. Dedicated leaders have been working hard to leverage their collective expertise. Recommendations for definitions, processes, knowledge translation tools, and programs that raise awareness about maternal mortality in Canada have been developed and are being piloted. It is anticipated that, with the appropriate support and appropriate leadership, Canada will have the foundation of a national confidential enquiry system into maternal deaths very soon. This is an update on progress.

Health outcomes of young children born to mothers who received 2009 pandemic H1N1 influenza vaccination during pregnancy: retrospective cohort study

OBJECTIVE

To determine whether any association exists between exposure to 2009 pandemic H1N1 (pH1N1) influenza vaccination during pregnancy and negative health outcomes in early childhood.

DESIGN

Retrospective cohort study.

SETTING

Population based birth registry linked with health administrative databases in the province of Ontario, Canada.

PARTICIPANTS

All live births from November 2009 through October 2010 (n=104 249) were included, and children were followed until 5 years of age to ascertain study outcomes.

MAIN OUTCOME MEASURES

Rates of immune related (infectious diseases, asthma), non-immune related (neoplasms, sensory disorders), and non-specific morbidity outcomes (urgent or inpatient health services use, pediatric complex chronic conditions) were evaluated from birth to 5 years of age; under-5 childhood mortality was also assessed. Propensity score weighting was used to adjust hazard ratios, incidence rate ratios, and risk ratios for potential confounding.

RESULTS

Of 104 249 live births, 31 295 (30%) were exposed to pH1N1 influenza vaccination in utero. No significant associations were found with upper or lower respiratory infections, otitis media, any infectious diseases, neoplasms, sensory disorders, urgent and inpatient health services use, pediatric complex chronic conditions, or mortality. A weak association was observed between prenatal pH1N1 vaccination and increased risk of asthma (adjusted hazard ratio 1.05, 95% confidence interval 1.02 to 1.09) and decreased rates of gastrointestinal infections (adjusted incidence rate ratio 0.94, 0.91 to 0.98). These results were unchanged in sensitivity analyses accounting for any potential differential healthcare seeking behavior or access between exposure groups.

CONCLUSIONS

No associations were observed between exposure to pH1N1 influenza vaccine during pregnancy and most five year pediatric health outcomes. Residual confounding may explain the small associations observed with increased asthma and reduced gastrointestinal infections. These outcomes should be assessed in future studies.

A mixed-methods evaluation of the MOREOB program in Ontario hospitals: participant knowledge, organizational culture, and experiences

BACKGROUND

MOREOB (Managing Obstetrical Risk Efficiently) is a patient safety program for health care providers and administrators in hospital obstetric units. MOREOB has been implemented widely in Canada and gradually spread to the United States. The main goal of MOREOB is to build a patient safety culture and improve clinical outcomes. In 2013, 26 Ontario hospitals voluntarily accepted provincial funding to participate in MOREOB. The purpose of our study was to assess the effect of MOREOB on participant knowledge, organizational culture, and experiences implementing and participating in the program at these 26 Ontario hospitals.

METHODS

A convergent parallel mixed-methods study in Ontario, Canada, with MOREOB participants from 26 hospitals. The quantitative component used a descriptive pre-post repeated measures design to assess participant knowledge and perception of culture, administered pre-MOREOB and after each of the three MOREOB modules. Changes in mean scores were assessed using mixed-effects regression. The qualitative component used a qualitative descriptive design with individual semi-structured interviews. We used content analysis to code, categorize, and thematically describe data. A convergent parallel design was used to triangulate findings from data sources.

RESULTS

308 participants completed the knowledge test, and 329 completed the culture assessment at all four time points. Between baseline and post-Module 3, statistically significant increases on both scores were observed, with an increase of 7.9% (95% CI: 7.1 to 8.8) on the knowledge test and an increase of 0.45 (on a scale of 1-5, 95% CI: 0.38 to 0.52) on the culture assessment. Interview participants (n = 15) described improvements in knowledge, interprofessional communication, ability to provide safe care, and confidence in skills. Facilitators and barriers to program implementation and sustainability were identified.

CONCLUSIONS

Participants were satisfied with their participation in the MOREOB program and perceived that it increased health care provider knowledge and confidence, improved safety for patients, and improved communication between team members. Additionally, mean scores on knowledge tests for obstetric content and culture assessment improved. The MOREOB program can help organizations and individuals improve care by concentrating on the human and organizational aspects of patient safety. Further work to improve program implementation and sustainability is required.

Effect of implementation of the MOREOB program on adverse maternal and neonatal birth outcomes in Ontario, Canada: a retrospective cohort study

Background

In 2002, the MORE^OB (Managing Obstetrical Risk Efficiently) obstetrical patient safety program was phased-in across hospitals in Ontario, Canada. The purpose of our study was to evaluate the effect of the MORE^OB program on rates of adverse maternal and neonatal outcomes.

Methods

A retrospective cohort study, using province-wide administrative hospitalization data. We included maternal and neonatal records between fiscal years 2002–2003 and 2013–2014, for deliveries taking place at the 67 Ontario hospitals where the MORE^OB program was implemented between 2002 and 2012. After accounting for institutional mergers and excluding very small hospitals, 55 hospitals (1,447,073 deliveries) were included.

Multivariable logistic and linear mixed effects regression analysis were used, accounting for secular trends, within hospital correlation and over time correlation, and adjusting for a maternal comorbidity index, hospital annual birth volume, and level of care.

The main outcome measure was a composite individual-level indicator of incidence of any adverse events, and a hospital-level score, called the Weighted Adverse Outcome Score (WAOS) capturing both maternal and neonatal adverse outcomes.

Results

Across the 12 years of follow up, there were 98,789 adverse maternal and neonatal outcomes, a rate of 6.83 per 100 deliveries (6.66 per 100 occurring before, 6.91 per 100 during, and 6.84 per 100 after program implementation). The multivariable analysis found no statistically significant decrease in adverse events associated with program implementation (OR for adverse events after versus before =1.11 (95% CI: 1.06 to 1.17, change in mean WAOS score after minus before =0.15 (− 0.36 to 0.67)).

Conclusions

We did not find a reduction in the incidence of maternal and neonatal adverse outcomes associated with the MORE^OB program, and small yet statistically significant increases in some adverse events were observed.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2296-5) contains supplementary material, which is available to authorized users.

Use of a maternal newborn audit and feedback system in Ontario: a collective case study

Background

As part of a larger study examining the effectiveness of the Maternal Newborn Dashboard, an electronic audit and feedback system to improve maternal-newborn care practices and outcomes, the purpose of this study was to increase our understanding of factors explaining variability in performance after implementation of the Dashboard in Ontario, Canada.

Methods

A collective case study. A maximum variation sampling approach was used to invite hospitals reflecting different criteria to participate in a 1-day to 2-day site visit by the research team. The visits included: (1) semistructured interviews and focus groups with healthcare providers, leaders and personnel involved in clinical change processes; (2) observations and document review. Interviews and focus groups were audio-recorded and transcribed verbatim. Qualitative content analysis was used to code and categorise the data.

Results

Between June and November 2016, we visited 14 maternal-newborn hospitals. Hospitals were grouped into four quadrants based on their key indicator performance and level of engagement with the Dashboard. Findings revealed four overarching themes that contribute to the varying success of sites in achieving practice change on the Dashboard key performance indicators, namely, interdisciplinary collaboration and accountability, application of formal change strategies, team trust and use of evidence and data, as well as alignment with organisational priorities and support.

Conclusion

The diversity of facilitators and barriers across the 14 hospitals highlights the need to go beyond a ‘one size fits all’ approach when implementing audit and feedback systems. Future work to identify tools to assess barriers to practice change and to evaluate the effects of cointerventions to optimise audit and feedback systems for clinical practice change is needed.

A population-based comparison of preterm neonatal deaths (22-34 gestational weeks) in France and Ontario: a cohort study

BACKGROUND

The management and outcomes of preterm births can vary greatly even among developed nations with the same access to medicine, technology and expertise. We aimed to compare aspects of obstetrical management and mortality for preterm infants in France and Ontario, Canada.

METHODS

The Better Outcomes Registry & Network (BORN) Information System in Ontario and Épidémiologique sur les petits âges gestationnels (EPIPAGE-2) in France collected information on maternal demographics, obstetrical characteristics, obstetrical interventions and neonatal outcomes for infants born between 22 and 34 weeks gestation. We used standardized covariate definitions and extracted data from 2011 (for EPIPAGE-2) and from 2012 and 2013 (for BORN) to conduct a cohort study comparing the 2 data sets (stratified into gestational age groups of 22-26, 27-31 and 32-34 wk) using multivariable logistic regression models.

RESULTS

Mothers in the BORN cohort were older (30.7 yr v. 29.6 yr) but less likely to have gestational hypertension (13.4% v. 17.9%) than those in the EPIPAGE-2 cohort. Infants from EPIPAGE-2 had lower birth weights (1.3 kg v. 1.5 kg) and were more likely to be born in an institution with level 3 care (71.9% v. 55.8%). After adjustment for these differences, there was significantly higher neonatal mortality among infants from EPIPAGE-2 in the 22-26 week gestation age group (adjusted odds ratio 2.81; 95% confidence interval 1.17 to 6.74).

INTERPRETATION

Even after we adjusted for both intrinsic population differences and differences in management between Ontario and France, we found a higher rate of neonatal mortality at earlier gestational ages in France. This may be related to differences in ethical approaches and/or postnatal management and should be explored further.

Outcomes for the First Year of Ontario's Birth Center Demonstration Project

INTRODUCTION

In 2014, Ontario opened 2 stand-alone midwifery-led birth centers. Using mixed methods, we evaluated the first year of operations for quality and safety, client experience, and integration into the maternity care community. This article reports on our study of safety and quality of care.

METHODS

This descriptive evaluation focused on women admitted to a birth center at the beginning of labor. For context, we matched this cohort (on a 1:4 basis) with similar low-risk midwifery clients giving birth in a hospital. Data sources included Ontario's Better Outcomes Registry and Network (BORN) Information System, the Canadian Institute for Health Information, Ontario census data, and birth center records.

RESULTS

Of 495 women admitted to a birth center, 87.9% experienced a spontaneous vaginal birth, regardless of the eventual location of birth, and 7.7% had a cesarean birth. The transport rate to a hospital was 26.3%. When compared with midwifery clients with a planned hospital birth, rates of intervention (epidural analgesia, labor augmentation, assisted vaginal birth, and cesarean birth) were significantly lower in the planned birth center group, even when controlled for previous cesarean birth and body mass index. Markers of potential morbidity were identified in about 10% of birth center births; however, there were no short-term health impacts up to discharge from midwifery care at 6 weeks postpartum. Care was low in intervention and safe (minimal negative outcomes and transport rates comparable to the literature).

DISCUSSION

In the first year of operation, care was consistent with national guidelines, and morbidity and mortality rates and intervention rates were low for women with low-risk pregnancies seeking a low-intervention approach for labor and birth. Further evaluation to confirm these findings is required as the number of births grows.

The Integration of Ontario Birth Centers into Existing Maternal-Newborn Services: Health Care Provider Experiences

INTRODUCTION

In 2014, 2 freestanding, midwifery-led birth centers opened in Ontario, Canada. The purpose of this study was to qualitatively investigate the integration of the birth centers into the local, preexisting intrapartum systems from the perspective of health care providers and managerial staff.

METHODS

Focus groups or interviews were conducted with health care providers (paramedics, midwives, nurses, physicians) and managerial staff who had experienced urgent and/or nonurgent maternal or newborn transports from a birth center to one of 4 hospitals in Ottawa or Toronto. A descriptive qualitative approach to data analysis was undertaken.

RESULTS

Twenty-four health care providers and managerial staff participated in a focus group or interview. Participants described positive experiences transporting women and/or newborns from the birth centers to hospitals; these positive experiences were attributed to the collaborative planning, training, and communication that occurred prior to opening the birth centers. The degree of integration was dependent on hospital-specific characteristics such as history, culture, and the presence or absence of midwifery privileging. Participants described the need for only minor improvements to administrative processes as well as the challenge of keeping large numbers of staff updated with respect to urgent transport policies. Planning and opening of the birth centers was seen as a driving force in further integrating midwifery care and improving interprofessional practice.

DISCUSSION

The collaborative approach for the planning and implementation of the birth centers was a key factor in the successful integration into the existing maternal-newborn system and contributed to improving integrated professional practice among midwives, paramedics, nurses, and physicians. This approach may be used as a template for the integration of other new independent health care facilities and programs into the existing health care system.

Parental characteristics and perspectives pertaining to neonatal visits to the emergency department: a multicentre survey

BACKGROUND

Parents take neonates to the emergency department for many reasons, often nonurgent, pressuring an already burdened system. We aimed to characterize these visits and families to identify potential strategies to decrease neonatal emergency department visits.

METHODS

We developed and implemented a survey that explored characteristics of neonates and parents/guardians evaluated in the emergency department, perspectives of parents and use of health care services. Parents presenting with a neonate to the emergency department in 5 large academic hospitals in Ontario were surveyed between December 2013 and June 2015. We used descriptive statistics to report survey data and explored correlations between factors.

RESULTS

A total of 1533 surveys were completed. The most common reasons for presenting were jaundice (441 [28.8%]) and feeding issues (251 [16.4%]). The majority of respondents (73.9% [1104/1494]) had received advice before going to the emergency department. In most cases (86.4% [954/1104]), this was from a health care provider, who frequently advised going to the emergency department. Although most parents (86.8% [1280/1475]) reported high confidence in caring for a sick or injured child, 42.3% (643/1519) were unsure of the severity, and most (90.4% [578/639]) of these parents felt that the infant required assessment immediately or the same day. Of parents who felt the condition was not serious, 83.2% (198/238) thought that same-day evaluation was required. Nearly half of respondents (44.4% [621/1400]) said they would have gone to their health care provider with a same-day appointment, and 28.1% (344/1225) would have gone to their care provider with a next-day appointment.

INTERPRETATION

Parents' reported confidence in caring for sick or injured infants does not match the perceived urgency of neonatal conditions, which likely contributes to emergency department overuse. Any system to decrease nonurgent emergency department use by neonates would need to be immediately responsive, providing same-day help.

Effect of a population-level performance dashboard intervention on maternal-newborn outcomes: an interrupted time series study

OBJECTIVES

To assess the effect of the Maternal Newborn Dashboard on six key clinical performance indicators in the province of Ontario, Canada.

DESIGN

Interrupted time series using population-based data from the provincial birth registry covering a 3-year period before implementation of the Dashboard and 2.5 years after implementation (November 2009 through March 2015).

SETTING

All hospitals in the province of Ontario providing maternal-newborn care (n=94).

INTERVENTION

A hospital-based online audit and feedback programme.

MAIN OUTCOME MEASURES

Rates of the six performance indicators included in the Dashboard.

RESULTS

2.5 years after implementation, the audit and feedback programme was associated with statistically significant absolute decreases in the rates of episiotomy (decrease of 1.5 per 100 women, 95% CI 0.64 to 2.39), induction for postdates in women who were less than 41 weeks at delivery (decrease of 11.7 per 100 women, 95% CI 7.4 to 16.0), repeat caesarean delivery in low-risk women performed before 39 weeks (decrease of 10.4 per 100 women, 95% CI 9.3 to 11.5) and an absolute increase in the rate of appropriately timed group B streptococcus screening (increase of 2.8 per 100, 95% CI 2.2 to 3.5). The audit and feedback programme did not significantly affect the rates of unsatisfactory newborn screening blood samples or formula supplementation at discharge. No statistically significant effects were observed for the two internal control outcomes or the four external control indicators-in fact, two external control indicators (episiotomy and postdates induction) worsened relative to before implementation.

CONCLUSION

An electronic audit and feedback programme implemented in maternal-newborn hospitals was associated with clinically relevant practice improvements at the provincial level in the majority of targeted indicators.

Severe obesity in children 17 to 24 months of age: a cross-sectional study of TARGet Kids! and Better Outcomes Registry & Network (BORN) Ontario

OBJECTIVES

International data suggest the prevalence of severe obesity in young children may be increasing, yet no Canadian data are available. The objectives of this study were to examine definitions of severe obesity and to evaluate associated risk factors among young children in Ontario.

METHODS

A cross-sectional study was conducted in children 17 to 24 months of age using two Ontario data sources: TARGet Kids! (n = 3713) and BORN Ontario (n = 768). Body mass index z score (zBMI) definitions were adapted from the World Health Organization (WHO) (z score > 3) and the US Centers for Disease Control (CDC) (> 120% of the 95th percentile) and applied to define severe obesity in young children. Multinomial logistic regression was used to evaluate associations between demographic and pregnancy risk factors and zBMI categories.

RESULTS

A total of 1.1% (95% CI, 0.8-1.4) of children met the adapted WHO definition of severe obesity compared to 0.3% (95% CI, 0.2-0.6) using the CDC definition. Median neighbourhood household income (OR = 0.80, 95% CI, 0.69-0.93) and maternal pre-pregnancy BMI (OR = 1.08, 95% CI, 1.01-1.15) were associated with severe obesity in unadjusted analyses. After adjustment for potential confounders, the OR for the association between maternal pre-pregnancy BMI and severe obesity was 1.04 (95% CI, 0.94-1.15).

CONCLUSION

More than 1% of Ontario children met the adapted WHO definition of severe obesity in very early childhood. Modifiable risk factors were identified. Future studies are needed to understand the terminology, prevalence, and risk factors for severe obesity in young children across Canada.

Intermittent auscultation versus continuous fetal monitoring: exploring factors that influence birthing unit nurses' fetal surveillance practice using theoretical domains framework

Background

Intermittent Auscultation (IA) is the recommended method of fetal surveillance for healthy women in labour. However, the majority of women receive continuous electronic monitoring. We used the Theoretical Domains Framework (TDF) to explore the views of Birthing Unit nurses about using IA as their primary method of fetal surveillance for healthy women in labour.

Methods

Using a semi-structured interview guide, we interviewed a convenience sample of birthing unit nurses throughout Ontario, Canada to elicit their views about fetal surveillance. Interviews were recorded and transcribed verbatim. Transcripts were content analysed using the TDF and themes were framed as belief statements. Domains potentially key to changing fetal surveillance behaviour and informing intervention design were identified by noting the frequencies of beliefs, content, and their reported influence on the use of IA.

Results

We interviewed 12 birthing unit nurses. Seven of the 12 TDF domains were perceived to be key to changing birthing unit nurses’ behaviour The nurses reported that competing tasks, time constraints and the necessity to multitask often limit their ability to perform IA (domains Beliefs about capabilities; Environmental context and resources). Some nurses noted the decision to use IA was something that they consciously thought about with every patient while others stated it their default decision as long as there were no risk factors (Memory, attention and decision processes, Nature of behaviour). They identified positive consequences (e.g. avoid unnecessary interventions, mother-centered care) and negative consequences of using IA (e.g. legal concerns) and reported that the negative consequences can often outweigh positive consequences (Beliefs about consequences). Some reported that hospital policies and varying support from care teams inhibited their use of IA (Social influences), and that support from the entire team and hospital management would likely increase their use (Social influences; Behavioural regulation).

Conclusion

We identified potential influences on birthing unit nurses’ use of IA as their primary method of fetal surveillance. These beliefs suggest potential targets for behaviour change interventions to promote IA use.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1517-z) contains supplementary material, which is available to authorized users.

Association of Universal Bilirubin Screening With Socioeconomic Disparities in Newborn Follow-up

OBJECTIVE

To determine whether implementation of universal bilirubin screening in Ontario, Canada is associated with improved rates of recommended follow-up care across socioeconomic status (SES).

METHODS

We conducted a retrospective population-based cohort study of all babies born at ≥35 weeks' gestation and discharged to home within 72 hours from 97 hospitals between April, 2003 and February, 2011. We used linked administrative health data sets to measure recommended follow-up care (physician visit within 1 day of discharge for babies discharged ≤24 hours after birth, or physician visit within 2 days for babies discharged 24-72 hours after birth). We used maternal postal code and the Canadian Deprivation Index to determine material deprivation quintile. We modeled the relationship between universal bilirubin screening and outcomes using generalized estimating equations to account for clustering according to hospital, underlying temporal trends, and important covariates.

RESULTS

Universal bilirubin screening was associated with a modest increase in recommended follow-up from 29.9% to 35.0% (n = 711,242; adjusted relative risk: 1.11; P = .047). Disparity in recommended follow-up increased after screening implementation, with 40% of the crude increase attributable to the highest SES quintile and none to the lowest SES quintile.

CONCLUSIONS

Universal bilirubin screening has had only a modest effect in ensuring timely follow-up for Ontario newborn babies, which represents an ongoing weakness in efforts to prevent severe hyperbilirubinemia. The observed increase in SES disparity in access to recommended follow-up suggests that universal programs that fail to address root causes of disparities might lead to overall improvements in population outcomes but increased inequity.

Infant Respiratory Outcomes Associated with Prenatal Exposure to Maternal 2009 A/H1N1 Influenza Vaccination

BACKGROUND

Infants are at high risk for influenza illness, but are ineligible for vaccination before 6 months. Transfer of maternal antibodies to the fetus has been demonstrated for 2009 A/H1N1 pandemic vaccines; however, clinical effectiveness is unknown. Our objective was to evaluate the association between 2009 A/H1N1 pandemic vaccination during pregnancy and rates of infant influenza and pneumonia.

METHODS

We linked a population-based birth cohort to administrative databases to measure rates of influenza and pneumonia diagnosed during ambulatory physician visits, hospitalizations and emergency department visits during one year of follow-up. We estimated incidence rate ratios and 95% confidence intervals (95% CI) using Poisson regression, comparing infants born to A/H1N1-vaccinated women (vaccine-exposed infants) with unexposed infants, adjusted for confounding using high-dimensional propensity scores.

RESULTS

Among 117,335 infants in the study, 36,033 (31%) were born to A/H1N1-vaccinated women. Crude rates of influenza during the pandemic (per 100,000 infant-days) for vaccine-exposed and unexposed infants were similar (2.19, 95% CI: 1.27-3.76 and 3.60, 95% CI: 2.51-5.14, respectively), as were crude rates of influenza and pneumonia combined. We did not observe any significant differences in rates of study outcomes between study groups during the second wave of the 2009 A/H1N1 pandemic, nor during any post-pandemic time period.

CONCLUSION

We observed no difference in rates of study outcomes among infants born to A/H1N1-vaccinated mothers relative to unexposed infants born during the second A/H1N1 pandemic wave; however, due to late availability of the pandemic vaccine, the available follow-up time during the pandemic time period was very limited.

A mixed methods evaluation of the maternal-newborn dashboard in Ontario: dashboard attributes, contextual factors, and facilitators and barriers to use: a study protocol

Background

There are wide variations in maternal-newborn care practices and outcomes across Ontario. To help institutions and care providers learn about their own performance, the Better Outcomes Registry & Network (BORN) Ontario has implemented an audit and feedback system, the Maternal-Newborn Dashboard (MND), for all hospitals providing maternal-newborn care. The dashboard provides (1) near real-time feedback, with site-specific and peer comparison data about six key performance indicators; (2) a visual display of evidence-practice gaps related to the indicators; and (3) benchmarks to provide direction for practice change. This study aims to evaluate the effects of the dashboard, dashboard attributes, contextual factors, and facilitation/support needs that influence the use of this audit and feedback system to improve performance. The objectives of this study are to (1) evaluate the effect of implementing the dashboard across Ontario; (2) explore factors that potentially explain differences in the use of the MND among hospitals; (3) measure factors potentially associated with differential effectiveness of the MND; and (4) identify factors that predict differences in hospital performance.

Methods/design

A mixed methods design includes (1) an interrupted time series analysis to evaluate the effect of the intervention on six indicators, (2) key informant interviews with a purposeful sample of directors/managers from up to 20 maternal-newborn care hospitals to explore factors that influence the use of the dashboard, (3) a provincial survey of obstetrical directors/managers from all maternal-newborn hospitals in the province to measure factors that influence the use of the dashboard, and (4) a multivariable generalized linear mixed effects regression analysis of the indicators at each hospital to quantitatively evaluate the change in practice following implementation of the dashboard and to identify factors most predictive of use.

Discussion

Study results will provide essential data to develop knowledge translation strategies for facilitating practice change, which can be further evaluated through a future cluster randomized trial.

Factors Associated with Breastfeeding Initiation in Adolescent Pregnancies: A Cohort Study

PURPOSE

Adolescent mothers have a lower breastfeeding rate than adult women. The objective is to determine the association between multiple high-risk characteristics of pregnant adolescents with intention and initiation of breastfeeding.

METHODS

We conducted a retrospective population-based cohort study in Ontario (2006-2012) using the Better Outcomes Registry & Network (BORN) database. Breastfeeding outcomes of adolescent women (younger than 20 years) with a singleton live-born infant at term gestation (37 weeks or greater) were analyzed. The χ(2) and independent-sample t tests were used where appropriate. A multivariate logistic regression analysis was also performed.

RESULTS

This study included 22,023 adolescent women with complete breastfeeding information. Almost half (48.8%, n = 10,749) exclusively breastfed their infant at time of hospital discharge. Breastfeeding was significantly more likely in the older adolescents (odds ratio 1.10); other factors significantly associated with breastfeeding included intention to breastfeed, prenatal classes attendance, living in a higher-income neighborhood, having a spontaneous vaginal delivery, being a nonsmoker, not using substances during pregnancy, and not having any preexisting health problems or obstetrical complications (P < .0001). A significant interaction between smoking and intention to breastfeed was identified. Intention to breastfeed was found to be protective against the reduction in breastfeeding seen with smoking.

CONCLUSION

This large-cohort study confirms that high-risk factors are associated with lower breastfeeding in Canadian adolescent term singleton births. Breastfeeding intention is a very important driver of breastfeeding. These findings highlight the importance of early multidisciplinary adolescent pregnancy care targeting these risks factors and education in order to improve breastfeeding rates in this population.

Antiviral medication use in a cohort of pregnant women during the 2009-2010 influenza pandemic

Preventing influenza-like illness (ILI) during pregnancy with antiviral medication use (AVMU) can mitigate serious health risks to mother and foetus. We report on AVMU in pregnant women in Ontario, Canada, and describe characteristics of AVMU during the 2009-2010 H1N1 pandemic. Rates and risk estimates of AVMU were compared across multiple categories and stratified across ILI infection status. Increased AVMU was observed in women with influenza infections, active smokers, those vaccinated against influenza, and those with pre-existing co-morbidities. Decreased AVMU was observed in women with multiple gestations, and those in neighbourhoods of high immigrant concentrations. Our stratified analysis indicated that the observed patterns differed by ILI infection status. We demonstrated that once infected, women across multiple groups were equally likely to use antiviral medications. In this report we also propose possible clinical explanations for the observed differences in AVMU, which will be useful in planning prevention initiatives for future pandemics.

Universal bilirubin screening and health care utilization

OBJECTIVE

To evaluate the impact of the implementation of universal bilirubin screening on neonatal health care use in the context of a large jurisdiction with universal health insurance.

METHODS

We conducted a population-based retrospective cohort study of all newborns discharged after birth between April 2003 and February 2011 from 42 hospitals that implemented universal bilirubin screening between July 2007 and June 2010 in Ontario, Canada. We surveyed hospitals to determine their screening implementation date. We used multiple linked administrative health data sets to measure phototherapy use, length of stay (LOS), jaundice-related emergency department visits, and jaundice-related readmissions. We modeled the relationship between universal bilirubin screening and outcomes using generalized estimating equations to account for clustering by hospital, underlying temporal trends, and important covariates.

RESULTS

Screening was associated with an increase in phototherapy during hospitalization at birth (relative risk, 1.32; 95% confidence interval, 1.09-1.59) and a decrease in jaundice-related emergency department visits (relative risk, 0.79; 95% confidence interval, 0.64-0.96) but no statistically significant difference in phototherapy after discharge, LOS, or jaundice-related readmissions after accounting for preexisting temporal trends in health care service use and other patient sociodemographic and hospital characteristics.

CONCLUSIONS

Universal bilirubin screening may not be associated with increased neonatal LOS or increased subsequent hospital use. Our findings are relevant for determining the resource implications of universal bilirubin screening in Ontario. They highlight the limitations in generalizability of previous research on health care utilization associated with similar programs and underline the importance of context-specific local evaluation of guideline implementation.

Measuring quality in maternal-newborn care: developing a clinical dashboard

Pregnancy, birth, and the early newborn period are times of high use of health care services. As well as opportunities for providing quality care, there are potential missed opportunities for health promotion, safety issues, and increased costs for the individual and the system when quality is not well defined or measured. There has been a need to identify key performance indicators (KPIs) to measure quality care within the provincial maternal-newborn system. We also wanted to provide automated audit and feedback about these KPIs to support quality improvement initiatives in a large Canadian province with approximately 140 000 births per year. We therefore worked to develop a maternal-newborn dashboard to increase awareness about selected KPIs and to inform and support hospitals and care providers about areas for quality improvement. We mapped maternal-newborn data elements to a quality domain framework, sought feedback via survey for the relevance and feasibility of change, and examined current data and the literature to assist in setting provincial benchmarks. Six clinical performance indicators of maternal-newborn quality care were identified and evidence-informed benchmarks were set. A maternal-newborn dashboard with "drill down" capacity for detailed analysis to enhance audit and feedback is now available for implementation. While audit and feedback does not guarantee individuals or institutions will make practice changes and move towards quality improvement, it is an important first step. Practice change and quality improvement will not occur without an awareness of the issues.

Women's perspectives of the fetal fibronectin testing process: a qualitative descriptive study

Background

In 2009 the Ontario Ministry of Health and Long Term Care funded the implementation of province-wide fetal fibronectin testing in Ontario hospitals. This paper reports results from the provincial evaluation that sought to describe the experience of fetal fibronectin testing from the perspective of women with symptoms of preterm labour.

Methods

A descriptive qualitative design was used, employing semi-structured telephone and face-to-face interviews with women who had fetal fibronectin testing.

Results

Five hospitals participated in recruiting women for the study and 17 women were interviewed. Women described their experiences of fetal fibronectin testing as an emotional process that moves from expecting, to feeling, to hoping for reassurance; and then to re-defining what is required to feel reassured. Women described feeling anxious while waiting for fetal fibronectin results. When test results were negative, women described feeling a sense of relief that their symptoms would not likely lead to an imminent preterm birth. Women with positive results expressed feeling reassured by the care decisions and quick action taken by the health care team.

Conclusion

Fetal fibronectin testing was acceptable and beneficial to these women with symptoms of preterm labour. Implications for practice and future research are suggested.

The association between obstetrical interventions and late preterm birth

OBJECTIVE

There is concern that obstetric interventions (prelabor cesarean section and induced delivery) are drivers of late preterm (LP) birth. Our objective was to evaluate the independent association between obstetric interventions and LP birth and explore associated independent maternal and fetal risk factors for LP birth.

STUDY DESIGN

In this population-based cross-sectional study, the BORN Information System was used to identify all infants born between 34 and 40 completed weeks of gestation between 2005 and 2012 in Ontario, Canada. The association between obstetric interventions (preterm cesarean section and induced delivery) and LP birth (34 to 36 completed weeks' gestation vs 37 to 40 completed weeks' gestation) was assessed using generalized estimating equation regression.

RESULTS

Of 917,013 births between 34 and 40 weeks, 49,157 were LP (5.4%). In the adjusted analysis, "any obstetric intervention" (risk ratio [RR], 0.65; 95% confidence interval [CI], 0.57-0.74), induction (RR, 0.71; 95% CI, 0.61-0.82) and prelabor cesarean section (RR, 0.66; 95% CI, 0.59-0.74) were all associated with a lower likelihood of LP vs term birth. Several independent potentially modifiable risk factors for LP birth were identified including previous cesarean section (RR, 1.28; 95% CI, 1.16-1.40), smoking during pregnancy (RR, 1.28; 95% CI, 1.21-1.36) and high material (RR, 1.1; 95% CI, 1.03-1.18) and social (RR, 1.09; 95% CI, 1.02-1.16) deprivation indices.

CONCLUSION

After accounting for differences in maternal and fetal risk, LP births had a 35% lower likelihood of obstetric interventions than term births. Obstetric care providers may be preferentially avoiding induction and prelabor cesarean section between 34 and 37 weeks' gestation.

Implementation of the Canadian Paediatric Society's hyperbilirubinemia guidelines: A survey of Ontario hospitals

INTRODUCTION

In 2007, the Canadian Paediatric Society (CPS) published guidelines aimed at preventing severe hyperbilirubinemia.

OBJECTIVES

To determine whether hospitals had implemented these guidelines; to investigate how guideline-recommended care is organized; and to understand the factors influencing guideline implementation.

METHODS

The present study was an online survey conducted from December 2011 to May 2012 of all Ontario hospitals offering maternal-newborn services.

RESULTS

A total of 97 of 100 eligible hospitals responded. Seventy-seven of the 97 (79%) respondents reported having implemented universal neonatal bilirubin screening. Among these hospitals, hospital-based postdischarge follow-up was reported more frequently than follow-up at community-based locations: hospital laboratory (n=40 [52%]), mother-baby care unit (n=32 [42%]), outpatient clinic (n=25 [33%]), primary care provider in community (n=19 [25%]) and community laboratory (n=8 [10%]). The CPS guidelines were the most frequently reported factor influencing implementation (n=74 [96%]).

DISCUSSION

The survey provides valuable insight into the impact of a complex guideline in Canada's largest province. There was heterogeneity in how hospitals organized services, but there was a notable trend toward hospital-based postdischarge care. The shift to hospital-based care runs counter to current health policy directions and highlights the lack of integration among health care sectors.

CONCLUSION

The majority of Ontario hospitals implemented universal bilirubin screening following the release of the CPS guidelines. Further analysis is needed to determine the impact that the guidelines and the differences in implementation have had on clinical outcomes and the utilization of health services.

Evaluation of the impact of fetal fibronectin test implementation on hospital admissions for preterm labour in Ontario: a multiple baseline time-series design

OBJECTIVE

To determine the impact of a health system-wide fetal fibronectin (fFN) testing programme on the rates of hospital admission for preterm labour (PTL).

DESIGN

Multiple baseline time-series design.

SETTING

Canadian province of Ontario.

POPULATION

A retrospective population-based cohort of antepartum and delivered obstetrical admissions in all Ontario hospitals between 1 April 2002 and 31 March 2010.

METHODS

International Classification of Diseases codes in a health system-wide hospital administrative database were used to identify the study population and define the outcome measure. An aggregate time series of monthly rates of hospital admissions for PTL was analysed using segmented regression models after aligning the fFN test implementation date for each institution.

MAIN OUTCOME MEASURE

Rate of obstetrical hospital admission for PTL.

RESULTS

Estimated rates of hospital admission for PTL following fFN implementation were lower than predicted had pre-implementation trends prevailed. The reduction in the rate was modest, but statistically significant, when estimated at 12 months following fFN implementation (-0.96 hospital admissions for PTL per 100 preterm births; 95% confidence interval [CI], -1.02 to -0.90, P = 0.04). The statistically significant reduction was sustained at 24 and 36 months following implementation.

CONCLUSIONS

Using a robust quasi-experimental study design to overcome confounding as a result of underlying secular trends or concurrent interventions, we found evidence of a small but statistically significant reduction in the health system-level rate of hospital admissions for PTL following implementation of fFN testing in a large Canadian province.

The use of a quality indicator to reduce elective repeat Caesarean section for low-risk women before 39 weeks' gestation: the Eastern Ontario experience

OBJECTIVE

Elective repeat Caesarean section (ERCS) for low-risk women at < 39 weeks' gestation has consistently been associated with increased risks to the neonate, including respiratory morbidity, NICU admission, and lengthier hospital stays than ERCS at 39 to 40 weeks' gestation. The objective of this quality improvement project was to reduce high rates of ERCS < 39 weeks across the Eastern Ontario region.

METHODS

All hospitals within the region providing care during labour and birth (n = 10) were asked to participate. Representatives from each hospital received information about their site-specific rates and knowledge-translation resources to assist them with the project. A benchmark rate for ERCS < 39 weeks was set at 30%. The rates of ERCS < 39 weeks were calculated for two different times (the 2009-2010 and 2010-2011 fiscal years) and the relative difference and 95% confidence intervals were calculated to quantify the magnitude and statistical significance of any change. Qualitative interviews were completed with key informants from each hospital.

RESULTS

The proportion of ERCS at < 39 weeks' gestation across the region in the fiscal year 2010-2011 (n = 197/497; 39.6%) was significantly decreased (relative difference: -21%; 95% CI -31% to -8%, P = 0.002) from the previous fiscal year 2009-2010 (n = 229/459; 49.9%). A number of barriers to, and facilitators of, practice change were identified.

CONCLUSION

A reduction in the rate of ERCS < 39 weeks among low-risk women was achieved across the region. Awareness of the issue, possession of site-specific data, and agreement about the evidence and the need for change are critical first steps to improving practice.

Occurrence and predictors of vacuum and forceps used sequentially for vaginal birth

BACKGROUND

Sequential use of vacuum and obstetric forceps for vaginal delivery is associated with increased risks of adverse maternal and infant outcomes.

METHODS

We conducted a retrospective cohort study to estimate the frequency of sequential use of vacuum and forceps for planned vaginal delivery and to identify predictors, using data collected in Ontario between 2004 and 2007. Multivariate logistic regression models were used to estimate the adjusted odds ratios and 95% confidence intervals of predictors of sequential use of vacuum and forceps.

RESULTS

Of 186 988 pregnant women with a singleton, vertex presentation at term and a planned vaginal birth, 1062 (0.57%) required the sequential use of vacuum and forceps for delivery. The major predictors for sequential use of vacuum and forceps were mother's primary language being other than English or French, nulliparity, a history of Caesarean section, dystocia, use of epidural or other pain relief, labour induction, labour augmentation, fetal macrosomia, and advanced gestational age.

CONCLUSION

In this population-based study we found that 0.57% of planned vaginal births were delivered with sequential use of vacuum and obstetric forceps. Abnormal labour, fetal macrosomia, language barriers, and advanced gestational age are significant predictors of requiring this sequential use.

H1N1 influenza vaccination during pregnancy and fetal and neonatal outcomes

OBJECTIVES

We evaluated the relationship between maternal H1N1 vaccination and fetal and neonatal outcomes among singleton births during the 2009-2010 H1N1 pandemic.

METHODS

We used a population-based perinatal database in Ontario, Canada, to examine preterm birth (PTB), small-for-gestational-age (SGA) births, 5-minute Apgar score below 7, and fetal death via multivariable regression. We compared outcomes between women who did and did not receive an H1N1 vaccination during pregnancy.

RESULTS

Of the 55,570 mothers with a singleton birth, 23,340 (42.0%) received an H1N1 vaccination during pregnancy. Vaccinated mothers were less likely to have an SGA infant based on the 10th (adjusted risk ratio [RR]=0.90; 95% confidence interval [CI]=0.85, 0.96) and 3rd (adjusted RR=0.81; 95% CI=0.72, 0.92) growth percentiles; PTB at less than 32 weeks' gestation (adjusted RR=0.73; 95% CI=0.58, 0.91) and fetal death (adjusted RR=0.66; 95% CI=0.47, 0.91) were also less likely among these women.

CONCLUSIONS

Our results suggest that second- or third-trimester H1N1 vaccination was associated with improved fetal and neonatal outcomes during the recent pandemic. Our findings need to be confirmed in future studies with designs that can better overcome concerns regarding biased estimates of vaccine efficacy.

The Ottawa Hospital’s Clinical Practice Guidelinefor the Second Stage of Labour

The management of the second stage of labour remains controversial, and there are very few comprehensive evidence-based clinical practice guidelines to assist care providers. We describe an approach to developing a local clinical practice guideline that included extensive review of the literature; use of a guideline appraisal instrument to assess methodological rigour, content, clarity and applicability; use of a recommendation matrix; drafting a local guideline; obtaining formal feedback; making revisions; and designing an implementation and evaluation plan. Recommendations from this guideline include timelines for the total length of second stage, waiting time, and pushing time. Positioning of the woman, use of oxytocin, and fetal assessment are also discussed. This guideline is not intended to be used for women with multiple gestation and women attempting vaginal birth after Caesarean (VBAC) or in clinical situations where little evidence on best practice exists and management is individualized. We advocate an approach to the second stage of labour that enhances patient safety through team planning, communication, and documentation.

The Evolution of Bed Rest as a Clinical Intervention

Bed rest as a therapy can be traced back to Hippocrates and has been used for many types of illnesses since then. It is still commonly used as an intervention in pregnancy despite known physiological and psychological side effects. Some historical and social reasons why nurses and other health care providers are slow to change practice are provided. Evidence from randomized trials is urgently needed to support or refute the use of bed rest in pregnancy.