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Abstract Background Evidence of associations between prenatal cannabis use (PCU) and maternal and infant health outcomes remains conflicting amid broad legalization of cannabis across Canada and 40 American states. A critical limitation of existing evidence lies in the non-standardized and crude measurement of prenatal cannabis use (PCU), resulting in high risk of misclassification bias. We developed a standardized tool to comprehensively measure prenatal cannabis use in pregnant populations for research purposes. Methods We conducted a mixed-methods, patient-oriented tool development and validation study, using a bias-minimizing process. Following an environmental scan and critical appraisal of existing prenatal substance use tools, we recruited pregnant participants via targeted social media advertising and obstetric clinics in Alberta, Canada. We conducted individual in-depth interviews and cognitive interviewing in separate sub-samples, to develop and refine our tool. We assessed convergent and discriminant validity internal consistency and 3-month test–retest reliability, and validated the tool externally against urine-THC bioassays. Results Two hundred fifty four pregnant women participated. The 9-item Cannabis Exposure in Pregnancy Tool (CEPT) had excellent discriminant (Cohen’s kappa = -0.27–0.15) and convergent (Cohen’s kappa = 0.72–1.0) validity; as well as high internal consistency (Chronbach’s alpha = 0.92), and very good test–retest reliability (weighted Kappa = 0.92, 95% C.I. [0.86–0.97]). The CEPT is valid against urine THC bioassay (sensitivity = 100%, specificity = 82%). Conclusion The CEPT is a novel, valid and reliable measure of frequency, timing, dose, and mode of PCU, in a contemporary sample of pregnant women. Using CEPT (compared to non-standardized tools) can improve measurement accuracy, and thus the quality of research examining PCU and maternal and child health outcomes.

Background: Hypertension is one of the most common medical problems during pregnancy. Hypertensive disorders of pregnancy (HDP) increase the risk of premature cardiovascular disease (CVD) 2- to 4-fold within 10 years after delivery. Early health behaviour modifications may prevent or manage several cardiovascular risk factors. Importantly, compared with women without HDP, fewer women with HDP achieve national dietary guidelines to prevent CVD. This highlights an opportunity for programs tailored for women post-HDP to support their nutritional behaviours as a key component of postpartum CVD preventive care. This systematic review investigated the impacts of nutrition modifications on lowering measures of CVD risk after HDP. Methods: Four electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library) were searched in October 2022 with a search strategy focused on nutrition programs/interventions and women post-HDP. Additional inclusion criteria were original research and reported outcome of CVD risk or cardiovascular risk factors. Results: Six studies were included: 4 experimental trials and 2 prospective cohort studies. Of the nutrition interventions, 4 were embedded within comprehensive health behaviour intervention programs. Outcome measures varied, but all studies reported blood pressure. A narrative synthesis found that the range of changes in blood pressure varied from no change to clinically meaningful change. Conclusions: This review found statistically nonsignificant yet clinically important improvements in measures of cardiovascular risk across a range of nutritional interventions in women after HDP. Further high-quality evidence is needed to inform the design and implementation of nutritional preventive cardiovascular care targeting this high CVD-risk population. Résumé: Contexte: L’hypertension est l’un des problèmes médicaux les plus fréquents durant la grossesse. Les troubles hypertensifs de la grossesse (THG) font augmenter le risque de maladies cardiovasculaires (MCV) prématurées de 2 à 4 fois dans les 10 années après l’accouchement. Des modifications précoces des comportements liés à la santé peuvent permettre de prévenir ou de prendre en charge plusieurs facteurs de risque cardiovasculaire. Notamment, par rapport aux femmes sans THG, moins de femmes atteintes de THG se conforment aux lignes directrices nationales en matière d’alimentation pour prévenir les MCV. D’où la possibilité qui s’offre aux programmes adaptés aux femmes post-THG d’encourager l’adoption de leurs comportements nutritionnels, une composante essentielle des soins de prévention des MCV dans la période du post-partum. La présente revue systématique visait à examiner les répercussions des modifications nutritionnelles sur la réduction des mesures du risque de MCV après les THG. Méthodes: En octobre 2022, nous avons effectué des recherches dans 4 bases de données électroniques (MEDLINE, Embase, CINAHL, Cochrane Library) au moyen d’une stratégie de recherche axée sur les interventions/programmes nutritionnels et les femmes post-THG. Les critères d’inclusion supplémentaires étaient la recherche initiale et les résultats signalés du risque de MCV ou des facteurs de risque cardiovasculaire. Résultats: Nous avons tenu compte de 6 études : 4 essais expérimentaux et 2 études de cohorte prospectives. Parmi les interventions nutritionnelles, 4 étaient intégrées aux programmes exhaustifs d’interventions sur les comportements liés à la santé. Les critères de jugement variaient, mais la pression artérielle était signalée dans toutes les études. Une synthèse narrative a permis de constater que l’étendue des changements dans la pression artérielle allait d’une absence de changement à des changements significatifs sur le plan clinique. Conclusions: Cette revue a permis de constater des améliorations non significatives sur le plan statistique, mais importantes sur le plan clinique des mesures du risque cardiovasculaire de différentes interventions nutritionnelles chez les femmes après les THG. D’autres données probantes de grande qualité sont nécessaires pour faciliter l’élaboration et la mise en œuvre de soins de prévention nutritionnelle des maladies cardiovasculaires visant cette population exposée à un risque élevé de MCV.

Objective: The Good Life with osteoArthritis: Denmark (GLA:D™) program for knee and hip osteoarthritis has been shown to be effective, but evaluations have yet to explore whether effectiveness differs by program context. The present study explores whether there are differences in effectiveness of the GLA:D™ program for treatment of hip and knee osteoarthritis across program location (i.e., rural, urban, metro) and program payor (i.e., public, private) within Alberta, Canada. Design: The study population was adults with hip or knee osteoarthritis attending the 8-week GLA:D™ supervised exercise and education programme in Alberta between Sep 2017–Mar 2020. Outcomes of interest were joint-related pain and quality of life (HOOS/KOOS), health quality of life (EQ-5D-5L), and performance-based functional (30-s chair stand test; 40-m walk test) measures. Minimally clinically important changes were calculated for each outcome and ANOVA and chi-square tests were used to determine statistical significance by program location or payor. Results: Of the 1321 eligible participants, 974 (73.7%) completed the baseline questionnaire, about 50% of participants participated in a metro area and 60% paid privately for the program. There were no statistically significant differences in improvements of joint-related pain, joint-related quality of life, health-related quality of life, or performance-based functional measures by program location or program payor, except for participants who received the program in a publicly covered primary care clinic who experienced significantly larger improvements in joint-related pain. Conclusion: The implementation of the GLA:D™ program for the treatment of knee and hip osteoarthritis in Alberta is effective across a range of contexts.

Abstract Background Antenatal depression (AD) is the most common complication of pregnancy in developed countries and increases the risk of preterm birth (PTB). Many pregnant individuals with AD do not obtain treatment due in part to risks associated with antidepressant medications, the expense and wait times for psychological services, and perceived stigma. Accessible and timely treatment of antenatal depression is crucial to minimize foetal impacts and associated long-term child health outcomes. Previous studies show that behavioural activation and peer support are promising avenues of treatment for perinatal depression. Additionally, remote and paraprofessional counselling interventions show promise as more accessible, sustainable, and cost-effective treatment avenues than traditional psychological services. The primary aim of this trial is to test the effectiveness of a remote, behavioural activation and peer support intervention, administered by trained peer para-professionals, for increasing gestational age at delivery among those with antenatal depression. The secondary aims are to evaluate the effectiveness for treating AD prior to delivery, with persistence into the postpartum; improving anxiety symptoms; and improving parenting self-efficacy compared to controls. Methods A two-arm, single-blinded, parallel groups randomized controlled trial (RCT) with repeated measures will be conducted. Participants scoring >10 on the Edinburgh Postnatal Depression Scale will be recruited from the larger P3 cohort and invited to enroll. Assessments will be conducted prior to 27 weeks’ gestation at trial intake (T1), post-intervention, prior to delivery (T2), 5–6 months postpartum (T3), and 11–12 months postpartum (T4) and will include self-report questionnaires and linked medical records. Discussion Our remote, peer paraprofessional-delivered behavioural activation plus peer support intervention has the potential to successfully reduce symptoms of AD, which may in turn decrease the risk of PTB and subsequent health impacts. The current trial builds on previous findings and uses a patient-oriented approach to address priorities for patient care and to provide a cost-effective, accessible, and evidence-based treatment to pregnant individuals with AD. Trial registration International Standard Randomised Controlled Trial Number (ISRCTN) registry (ISRCTN51098220) ISRCTN51098220. Registered on April 7, 2022.

Abstract Background Breastfeeding difficulties frequently exacerbate one another and are common reasons for curtailed breastfeeding. Women with chronic conditions are at high risk of early breastfeeding cessation, yet limited evidence exists on the breastfeeding difficulties that co-occur in these mothers. The objective of this study was to explore clusters of breastfeeding difficulties experienced up to 6 weeks postpartum among mothers with chronic conditions and to examine associations between chronic condition types and breastfeeding difficulty clusters. Methods We analyzed 348 mothers with chronic conditions enrolled in a prospective, community-based pregnancy cohort study from Alberta, Canada. Data were collected through self-report questionnaires. We used latent class analysis to identify clusters of early breastfeeding difficulties and multinomial logistic regression to examine whether types of chronic conditions were associated with these clusters, adjusting for maternal and obstetric factors. Results We identified three clusters of breastfeeding difficulties. The “physiologically expected” cluster (51.1% of women) was characterized by leaking breasts and engorgement (reference outcome group); the “low milk production” cluster (15.4%) was discerned by low milk supply and infant weight concerns; and the “ineffective latch” cluster (33.5%) involved latch problems, sore nipples, and difficulty with positioning. Endocrine (adjusted relative risk ratio [RRR] 2.34, 95% CI 1.10–5.00), cardiovascular (adjusted RRR 2.75, 95% CI 1.01–7.81), and gastrointestinal (adjusted RRR 2.51, 95% CI 1.11–5.69) conditions were associated with the low milk production cluster, and gastrointestinal (adjusted RRR 2.44, 95% CI 1.25–4.77) conditions were additionally associated with the ineffective latch cluster. Conclusion Half of women with chronic conditions experienced clusters of breastfeeding difficulties corresponding either to low milk production or to ineffective latch in the first 6 weeks postpartum. Associations with chronic condition types suggest that connections between lactation physiology and disease pathophysiology should be considered when providing breastfeeding support.

Abstract Background An unplanned extubation is the uncontrolled and accidental removal of a breathing tube and is an important quality indicator in pediatric critical care. The objective of this review was to comprehensively synthesize literature published on quality improvement (QI) practices implemented to reduce the rate of unplanned extubations in critically ill children. Methods We included original, primary research on quality improvement interventions to reduce the rate of unplanned extubations in pediatric critical care. A search was conducted in MEDLINE (Ovid), Embase, and CINAHL from inception through April 29, 2021. Two reviewers independently screened citations in duplicate using pre-determined eligibility criteria. Data from included studies were abstracted using a tool created by the authors, and QI interventions were categorized using the Behavior Change Wheel. Vote counting based on the direct of effect was used to describe the effectiveness of quality improvement interventions. Study quality was assessed using the Quality Improvement Minimum Quality Criteria Set (QI-MQCS). Results were presented as descriptive statistics and narrative syntheses. Results Thirteen studies were included in the final review. Eleven described primary QI projects; two were sustainability studies that followed up on previously described QI interventions. Under half of the included studies were rated as high-quality. The median number of QI interventions described by each study was 5 [IQR 4–5], with a focus on guidelines, environmental restructuring, education, training, and communication. Ten studies reported decreased unplanned extubation rates after the QI intervention; of these, seven had statistically significant reductions. Both sustainability studies observed increased rates that were not statistically significant. Conclusions This review provides a comprehensive synthesis of QI interventions to reduce unplanned extubation. With only half the studies achieving a high-quality rating, there is room for improvement when conducting and reporting research in this area. Findings from this review can be used to support clinical recommendations to prevent unplanned extubations, and support patient safety in pediatric critical care. Systematic review registration This review was registered on PROSPERO (CRD42021252233) prior to data extraction.

Introduction: Our objective was to investigate differences in prevalence of hysterectomy by self-reported disability status among Canadian women. Materials and Methods: We analyzed cross-sectional data from the Canadian Community Health Survey 2012 on 30,170 women aged ?20 years. Disability was defined as reports of sometimes or often (vs. never) experiencing functional limitations or reduction in daily activities at home, school, or work. Frequency of these limitations was used as a proxy for disability severity. The outcome was self-reported hysterectomy status. Modified Poisson regression was used to quantify the prevalence ratio (PR) and 95% confidence interval (CI) for hysterectomy according to any, functional, or activity-limiting disability, after adjustment for household income, employment, education, ethnicity, and marital status. Results were stratified by age at time of data collection, categorized as childbearing (20?44 years), perimenopausal (45?59 years), and postmenopausal (60 years and older). Results: Disability was significantly and consistently associated with higher prevalence of hysterectomy in women. The strength of association was inversely related to age category, and PRs for a given age category were similar across disability types and severity levels. PRs for the association between any disability and hysterectomy were 2.18 (95% CI 1.36?3.50) for childbearing-aged women, 1.48 (95% CI 1.21?1.80) for perimenopausal women, and 1.12 (95% CI 1.02?1.24) for postmenopausal women. Conclusions: Prevalence of hysterectomy is disproportionately higher among women with self-reported disabilities compared with women without disabilities, with these differences most pronounced in women of childbearing age.

BackgroundUse of social media for study recruitment is becoming increasingly common. Previous studies have typically focused on using Facebook; however, there are limited data to support the use of other social media platforms for participant recruitment, notably in the context of a pregnancy study. ObjectiveOur study aimed to evaluate the effectiveness of Facebook, Twitter, and Instagram in recruiting a representative sample of pregnant women in a longitudinal pregnancy cohort study in Calgary, Alberta, between September 27, 2021, and April 24, 2022. MethodsPaid advertisements were targeted at 18- to 50-year-old women in Calgary, with interests in pregnancy. Data regarding reach, link clicks, and costs were collected through Facebook Ads Manager (Meta Platforms, Inc) and Twitter Analytics (Twitter, Inc). The feasibility of each platform for recruitment was assessed based on the recruitment rate and cost-effectiveness. The demographic characteristics of the participants recruited through each source were compared using the chi-square test. ResultsPaid advertisements reached 159,778 social media users, resulting in 2390 link clicks and 324 participants being recruited. Facebook reached and recruited the highest number of participants (153/324, 47.2%), whereas Instagram saw the highest number of link clicks relative to the number of users who saw the advertisement (418/19,764, 2.11%). Facebook and Instagram advertisements were cost-effective, with an average cost-per-click of CAD $0.65 (US $0.84; SD $0.27, US $0.35) and cost-per-completer of CAD $7.89 (US $10.25; SD CAD $4.08, US $5.30). Twitter advertisements were less successful in terms of recruitment and costs. Demographic characteristics of participants did not differ based on recruitment source, except for education and income, where more highly educated and higher-income participants were recruited through Instagram or Twitter. Many issues related to fraudulent responses were encountered throughout the recruitment period. ConclusionsPaid social media advertisements (especially Facebook and Instagram) are feasible and cost-effective methods for recruiting a large sample of pregnant women for survey-based research. However, future research should be aware of the potential for fraudulent responses when using social media for recruitment and consider strategies to mitigate this problem.

Abstract Background Prenatal medical risk describes physical health issues or biological factors that predate or arise during pregnancy which heighten the risk of adverse outcomes, and often warrant specialized obstetric care. The influence of the nature and magnitude of prenatal risk on breastfeeding outcomes remains poorly understood. The objective of this study was to determine the association between prenatal medical risk and breastfeeding initiation and duration up to 1 year postpartum. Methods We analysed a subset of data from the All Our Families longitudinal cohort (n = 2706) of women in Calgary, Canada who delivered a liveborn infant between 2008 and 2010. Data were collected from self-report questionnaires and medical records. Women with complete data on prenatal medical risk factors and breastfeeding outcomes were included in this analysis. Prenatal medical risk was operationalized as one integer score of risk severity and four binary risk types capturing pre-pregnancy characteristics, past obstetric problems, current obstetric problems, and substance use. Outcomes were breastfeeding initiation defined as the infant ever receiving breast milk, and duration operationalized as still breastfeeding at 4 months, at 12 months, and time to breastfeeding cessation in weeks. We used logistic regression and Cox regression with right censoring at 52 weeks or attrition to calculate odds ratios (OR) and hazard ratios (HR), respectively, adjusting for sociodemographic vulnerability, parity, mode of delivery, and gestational age. Results Prenatal medical risk severity and type were not significantly associated with breastfeeding initiation, with the exception of pre-pregnancy risk type (OR 0.45; 95% CI 0.26, 0.77). Risk severity was associated with lower odds of breastfeeding to 4 months (OR 0.94; 95% CI 0.90, 0.99), 12 months (OR 0.93; 95% CI 0.87, 0.98), and earlier breastfeeding cessation (HR 1.05; 95% CI 1.02, 1.08). Associations with shorter breastfeeding length across the first postpartum year were observed for pre-pregnancy, current obstetric, and substance use risk types, but not past obstetric problems. Conclusion Prenatal medical risk is associated with shortened duration of breastfeeding. Women with prenatal medical risk may benefit from the proactive arrangement of lactation support before and following delivery to promote continued breastfeeding.

Abstract Background Insomnia and sleep disturbances are common in pregnancy and have potentially significant consequences for both maternal and infant health. There is limited research examining the effectiveness of cognitive behavioral therapy for insomnia (CBT-I) during pregnancy. With increased distress and limited access to services during the COVID-19 pandemic, there is also an unprecedented need for telehealth delivery of treatment programs for pregnant women. The aims of this trial are to evaluate the impact of the Sleeping for Two adaptation of CBT-I in pregnancy (in-person or telehealth) versus treatment as usual (TAU) in reducing symptoms of insomnia (primary outcome), as well as increasing gestational length and reducing symptoms of depression (secondary outcomes). Methods A two-arm, single-blinded, parallel group randomized controlled trial (RCT) design with repeated measures will be used to evaluate the impact of CBT-I compared to TAU among a sample of 62 pregnant women, enrolled between 12 and 28 weeks of gestation, who self-identify as experiencing insomnia. Five weekly individual sessions of CBT-I will be delivered in person or via telehealth depending on physical distancing guidelines. Assessment of insomnia diagnosis by structured interview, self-reported insomnia symptom severity and sleep problems, and sleep quantity and quality as measured by a daily diary and actigraphy will occur at 12–28 weeks of pregnancy (T1), 1 week post-treatment (T2), and 6 months postpartum (T3). Discussion CBT-I delivered in pregnancy has the potential to reduce symptoms of insomnia and depression and could lead to reduced risk of preterm birth, all of which can minimize risk of negative maternal and child health and developmental consequences in the short (e.g., infant death) and long terms (e.g., developmental delays). This RCT builds on a successful open pilot trial conducted by our team and will provide further evaluation of a novel evidence-based treatment for pregnancy-related insomnia, which can be widely disseminated and used to treat individuals that are most in need of intervention. Findings will enhance understanding of pregnancy-related sleep problems, as well as means by which to improve the health and sleep of mothers and their children. Trial registration ClinicalTrials.gov NCT03918057. Registered on 17 April 2019.

Purpose Maternal fetal attachment (MFA) is the bond between the mother and her unborn baby. Presently no tools measuring MFA are available in Arabic. The aim of this study was to translate Muller’s Prenatal Attachment Inventory (PAI) from English to Arabic, examine the cultural appropriateness of this tool, and test its psychometric properties with pregnant women in an Arab country. Materials and methods The PAI was translated from English into Arabic using the Universal Translation Approach (modified tool) and assessed for content validity. During this process four additional items were identified for measurement relevance and cultural acceptability resulting in the revised tool. The psychometric properties of the modified and revised tools were assessed after 250 pregnant Arab women completed the PAI. Factor analysis was conducted to assess construct validity, while reliability was assessed using Cronbach’s alpha coefficient. Results Both tools were shown to be unidimensional with excellent reliability (Cronbach’s alpha = 0.88 for the modified tool and 0.89 for the revised tool). Nulliparity, planning to breastfeed the baby, feeling fetal movements, and downloading a smartphone app to follow the baby’s growth were associated with increased MFA in the PAI, while only planning to breastfeed the baby, feeling fetal movements, and downloading a smartphone app to follow the baby’s growth were associated with increased MFA in the revised PAI. Conclusion The Arabic version of the PAI is a culturally appropriate tool to measure MFA amongst Arabic-speaking women.

Background: Cardiovascular disease (CVD) is the leading cause of death in women globally. In recent years, attention has turned to infertility and pregnancy-related events as potential markers for early mortality and future CVD. Methods: The Study of Women’s Health Across the Nation (SWAN) is an ongoing longitudinal cohort study of women’s health. Women aged 42-52 years with a uterus and ≤ 1 intact ovary, a menstrual period, and no hormone medications within 3 months before enrollment were eligible. Infertility was self-reported and defined as the inability to achieve pregnancy after 12 months of trying to conceive, or use of fertility medications for > 1 month. Outcomes included development of metabolic syndrome over a 7-year follow-up, and any atherosclerotic CVD event (ie, stroke, angina, myocardial infarction) over a 10-year follow-up. Cox proportional hazards models were used to calculate hazard ratios (HRs) for metabolic syndrome and CVD events in participants with infertility, with adjustment for relevant covariates. Participants without infertility were used as the comparison group. Results: We included 2370 participants in the analysis of metabolic syndrome risk, and 2809 participants were included in the analysis of CVD event risk. Participants with self-reported infertility did not have a higher risk of developing metabolic syndrome (HR, 0.91; 95% confidence interval, 0.71-1.15) or experiencing CVD events (HR, 0.79; 95% confidence interval, 0.52-1.21) after adjusting for relevant covariates. Conclusions: Infertility was not associated with development of metabolic syndrome or CVD events in women; further research is required to investigate the effects of specific causes of infertility and fertility treatments on CVD outcomes. Résumé: Introduction: Les maladies cardiovasculaires (MCV) sont la principale cause de décès chez les femmes dans le monde. Au cours de dernières années, l’infertilité et les complications de la grossesse ont retenu l’attention, à savoir qu’ils constituent des marqueurs potentiels de la mortalité précoce et des MCV futures. Méthodes: La Study of Women’s Health Across the Nation (l’étude SWAN) qui constitue une étude de cohorte longitudinale sur la santé des femmes est en cours. Les femmes âgées de 42 à 52 ans qui ont un utérus et ≤ 1 ovaire intact, une période menstruelle et qui ne prenaient aucun médicament hormonal 3 mois avant le recrutement étaient admissibles. L’infertilité était autodéclarée et définie comme l’incapacité à être enceinte après 12 mois de tentatives de conception ou l’utilisation de médicaments pour traiter l’infertilité durant > 1 mois. L’issue était la suivante : la survenue du syndrome métabolique au cours du suivi de 7 ans ou de tout événement lié à la MCV athérosclérotique (c.-à-d. l’accident vasculaire cérébral, l’angine, l’infarctus du myocarde) au cours du suivi de 10 ans. Nous avons utilisé les modèles de risques proportionnels de Cox pour calculer les rapports de risque (RR) du syndrome métabolique et des événements liés aux MCV chez les participantes infertiles par l’ajustement des covariables pertinentes. Les participantes fertiles constituaient le groupe témoin. Résultats: Nous avons recruté 2 370 participantes pour l’analyse du risque de syndrome métabolique, et 2 809 participantes pour l’analyse du risque d’événements liés aux MCV. Les participantes qui avaient autodéclaré leur infertilité n’avaient pas de risque plus élevé de souffrir du syndrome métabolique (RR, 0,91 ; intervalle de confiance à 95 %, 0,71-1,15) ou de subir des événements liés aux MCV (RR, 0,79 ; intervalle de confiance à 95 %, 0,52-1,21) après l’ajustement des covariables pertinentes. Conclusions: L’infertilité n’était pas associée à la survenue du syndrome métabolique ou des événements liés aux MCV chez les femmes. D’autres recherches qui porteront sur les effets des causes particulières de l’infertilité et des traitements favorisant la fertilité sur l’évolution des MCV sont nécessaires.

Background This study examined the performance of multiple anxiety scales in measuring anxiety during pregnancy, an important issue due to the possible effect of pregnancy-related symptoms on the measurement of anxiety. Methods Secondary data on anxiety, measured by the State-Trait Anxiety Inventory-State (STAI-S) 20-item and six-item scales, the Edinburgh Postnatal Depression Scale-Anxiety Subscale (EPDS-3A) and the Symptoms Checklist-90-Anxiety Subscale (SCL-90), were obtained from two pregnancy cohort studies. Both cohorts completed the EPDS-3A, while 3341 women completed the STAI-S and 2187 women completed the SCL-90, with 231 women participating in both cohorts. Data were analyzed using confirmatory factor analysis and Spearman correlation. Results The STAI-6 had adequate model fit, while the STAI-20 and the SCL-90 had inadequate model fit. Model fitness for the EPDS-3A could not be assessed due to its low number of items. The correlation between the STAI-20 and STAI-6 was excellent (r = 0.93). The correlation of EPDS-3A with other anxiety scales was low to moderate (r (STAI-20) = 0.57, r (STAI-6) = 0.53 and r (SCL-90) = 0.44). The correlation of SCL-90 with both STAI-20 and STAI-6 was low (r

BackgroundPostmenopausal hormone therapy (HT) is associated with increased cardiovascular risk. Although the route of estrogen administration may play a role in mediating risk, previous studies have not controlled for concomitant progestin use.ObjectiveTo investigate the association between the route of estrogen therapy (oral or non-oral) HT use, without concomitant progestin, and blood pressure and arterial stiffness in postmenopausal women.MethodsSystolic blood pressure [SBP], diastolic blood pressure [DBP]), arterial stiffness (aortic pulse wave velocity [aPWV] and augmentation index at 75 beats per minute [AIx]) were measured using a validated automated brachial cuff-based oscillometric approach (Mobil-O-Graph) in a community-dwelling sample of 328 women.ResultsFifty-five participants (16.8%) were ever users (current and past use) of estrogen-only HT (oral [n = 16], transdermal [n = 20], vaginal [n = 19]), and 223 were never HT users (control). Ever use of oral estrogen was associated with increased SBP and DBP (Oral: SBP: 137 ± 4 mmHg, DBP: 79 ± 2 mmHg) compared to use of non-oral estrogen (transdermal: SBP: 118 ± 2 mmHg, DBP: 73 ± 1 mmHg; p < 0.01 & p = 0.012, respectively; vaginal: SBP: 123 ± 2 mmHg DBP: 73 ± 2 mmHg; p = 0.02 & p = 0.01, respectively.) and controls (SBP: 124 ± 1 mmHg, DBP: 74 ± 1 mmHg, p = 0.03, p = 0.02, respectively) after adjustment for covariates. aPWV was higher in oral estrogen ever users (9.9 ± 1 m/s) compared to non-oral estrogen (transdermal: 8.6 ± 0.3 m/s, p < 0.01; vaginal: 8.8 ± 0.7 m/s, p = 0.03) and controls (8.9 ± 0.5 m/s, p = 0.03) but these associations were no longer significant after adjustment for covariates. AIx was higher in oral estrogen (29 ± 2 %) compared to non-oral estrogen (transdermal: 16 ± 2 %; vaginal: 22 ± 1.7 %) but this association was no longer significant after adjustment for covariates (p = 0.92 vs. non-oral; p = 0.74 vs. control).ConclusionEver use of oral estrogen was associated with increased SBP and DBP compared to non-oral estrogen use and no use. Given the cardiovascular risk associated with both menopause and increased blood pressure, further studies are required exploring the potential benefits of non-oral estrogen in postmenopausal women.

Abstract Oral contraceptives (OC) are associated with increased risk of hypertension and elevated blood pressure (BP). Whether non‐oral hormonal contraceptives have similar associations is unknown. We sought to investigate the effect of non‐oral hormonal contraceptive (NOHC) use on the risk of hypertension and changes in BP, compared to non‐hormonal contraceptive and OC use. We searched bibliographic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) until August 2020. Studies reporting risk of hypertension or changes in systolic and diastolic BP with NOHC use compared with either non‐hormonal contraceptive or OC use. Abstract screening, full‐text review, data extraction, and quality assessment were completed in duplicate. For studies reporting dichotomous outcomes, we reported results as relative risk with 95% confidence intervals (CI). A random‐effects model was used to estimate pooled weighted mean difference and 95% CI of change in BP. Twenty‐five studies were included. A lower incidence of hypertension was observed with injectable contraceptive use compared to non‐hormonal contraceptive and OC use, although it was unclear if this was statistically significant. Compared to non‐hormonal contraceptive use, injectable contraceptive use was associated with increased BP (SBP: 3.24 mmHg, 95%CI 2.49 to 3.98 mmHg; DBP: 3.15 mmHg, 95%CI 0.09 to 6.20 mmHg), the hormonal intra‐uterine device use was associated with reduced BP (SBP: −4.50 mmHg, 95%CI −8.44 to −0.57 mmHg; DBP: −7.48 mmHg, 95% −14.90 to −0.05 mmHg), and the vaginal ring was associated with reduced diastolic BP (−3.90 mmHg, 95%CI −6.67 to −1.13 mmHg). Compared to OC use, the injectable contraceptive use was associated with increased diastolic BP (2.38 mmHg, 95%CI 0.39 to 4.38 mmHg). NOHC use is associated with changes in BP which differ by type and route of administration. Given the strong association between incremental increases in BP and cardiovascular risk, prospective studies are required.

Abstract The objective of this study was to identify distinct clusters of individuals that exhibit unique patterns of modifiable lifestyle-related behaviours and to determine how these patterns are associated with the risk of developing colorectal cancer (CRC). The study consisted of 26,460 participants and 267 CRC cases from Alberta’s Tomorrow Project. Exploratory latent class analysis of risk behaviours (obesity, physical inactivity, meat consumption, smoking, alcohol consumption, and fruit and vegetable consumption) and Cox proportional hazard models were utilized. Seven unique behavioural groups were identified, where the risk of CRC was 2.34 to 2.87 times greater for high risk groups compared to the low risk group. Sex-specific models identified higher risk groups among men (Hazard Ratios [HRs]: 3.15 to 3.89) than among women (HRs: 1.99 to 2.19). Targeting groups defined by clustering of behaviours could potentially lead to more effective prevention of CRC on a population level.

Abstract Background Pregnant women with inflammatory bowel disease (IBD) are more likely than the general pregnant population to experience adverse maternofetal outcomes, especially if the disease is active at the time of conception and during pregnancy. Elevated stress is often seen in patients with chronic diseases and could account for these outcomes. Salivary cortisol and alpha‐amylase (sAA) are novel biomarkers of stress, reflecting the hypothalamic‐pituitary‐adrenal (HPA) axis and sympathetic nervous system, respectively. Our aim in this pilot study was to assess stress differences between pregnant women with inactive IBD and matched controls using psychometric questionnaires and salivary biomarker measures. Methods Thirteen pregnant women with quiescent IBD (6 Crohn's disease, 7 ulcerative colitis) were matched (1:3) to 39 expectant mothers without IBD by parity and gestational age. Participants completed several psychometric questionnaires assessing stress, and salivary cortisol and sAA were collected as objective biomarkers of stress during pregnancy. Results Pregnant women with quiescent IBD did not demonstrate significant differences on any psychometric measures of stress or salivary biomarker measures when compared with controls (all P > 0.05). Pregnant women with quiescent IBD demonstrated similar cortisol and sAA awakening responses (both P > 0.05) and total levels of cortisol and sAA production (both P > 0.05) when compared with controls. Conclusions Pregnant women with well‐controlled IBD do not experience demonstrable differences in psychological stress or dysregulation of salivary stress biomarkers when compared with non‐IBD controls. The effect of chronic disease may be evaluated in future studies by including a comparative group of pregnant women with active IBD.

Abstract Background The average age at first birth is steadily increasing in developed countries; however, demographic shifts in maternal age at childbearing have not occurred in isolation. While temporal increases in adverse pregnancy outcomes are typically attributed to increases in maternal age, little is known about how maternal health status has changed across maternal age, period of delivery, and birth cohort. Methods Natality files were used to identify primiparous women delivering liveborn, singleton infants in the USA in 1989, 1994, 1999, 2004, 2009, and 2014 (n = 6,857,185). Age-period-cohort models using the intrinsic estimator adjusted for temporal trends in smoking and gestational weight gain were used to quantify temporal changes in the rates of pre-existing (chronic hypertension, pre-existing diabetes) and pregnancy-associated (pregnancy-associated hypertension, gestational diabetes, eclampsia) diseases. Log-linear models were used to model the impact of temporal changes on preterm birth, small, and large for gestational age (SGA/LGA) births. Results Significant period effects resulted in temporal increases in the rate of chronic hypertension, pregnancy-associated hypertension, and gestational diabetes, and a significant decrease in the rate of eclampsia. These observed period effects were associated with a 10.6% increase in the rate of SGA and a 7.1% decrease in LGA. Had the rate of pre-existing and pregnancy-associated diseases remained static over this time period, the rate of preterm birth would have increased by 5.9%, but instead only increased by 4.4%. Conclusions Independent of changes in the incidence of pre-existing and pregnancy-associated diseases as women age, the obstetric population is becoming less healthy over time. This is important, as these changes have a direct negative impact on short-term obstetric outcomes and women’s long-term health.

Abstract Introduction Sex influences the cardiovascular risk associated with body mass index (BMI) in older adults. Whether this risk differs by sex in younger adults is unknown. We aimed to evaluate the association between measures of adiposity and arterial stiffness and reninangiotensin‐aldosterone system (RAAS) activity in younger adults, stratified by sex. Methods Body mass index (BMI), waist circumference (WC), hip circumference (HC), waist‐to‐hip ratio (WHR), waist‐to‐height ratio (WHtR) and fat mass% (FM%) were measured in healthy participants in a fasting, high‐salt state. Arterial stiffness [pulse wave velocity (PWV) and aortic augmentation index (AIx)] were measured at baseline and in response to angiotensin II challenge, a validated marker of RAAS activity. Associations were evaluated using linear regression analysis and stratified by sex. Results Ninety‐five healthy, normotensive, non‐diabetic females (n = 67, 37 ± 2 y, BMI 25 ± 1 kg/m2) and males (n = 28, 39 ± 3 y, BMI 27 ± 1 kg/m2) participated in the study. No association was observed between any measure of adiposity and PWV, either at baseline or in response to angiotensin II challenge in premenopausal females. In contrast, all measures of adiposity except HC were associated with PWV at baseline (BMI r = 0.32; WC r = 0.18; WHtR r = 0.34; FM r = 0.21; all values p

Introduction Severe maternal morbidity (SMM)—an unexpected pregnancy-associated maternal outcome resulting in severe illness, prolonged hospitalisation or long-term disability—is recognised by many, as the preferred indicator of the quality of maternity care, especially in high-income countries. Obtaining comprehensive details on events and circumstances leading to SMM, obtained through maternity units, could complement data from large epidemiological studies and enable targeted interventions to improve maternal health. The aim of this study is to assess the feasibility of gathering such data from maternity units across Canadian provinces and territories, with the goal of establishing a national obstetric survey system for SMM in Canada.Methods and analysis We propose a sequential explanatory mixed-methods study. We will first distribute a cross-sectional survey to leads of all maternity units across Canada to gather information on (1) Whether the unit has a system for reviewing SMM and the nature and format of this system, (2) Willingness to share anonymised data on SMM by direct entry using a web-based platform and (3) Respondents’ perception on the definition and leading causes of SMM at a local level. This will be followed by semistructured interviews with respondent groups defined a priori, to identify barriers and facilitators for data sharing. We will perform an integrated analysis to determine feasibility outcomes, a narrative description of barriers and facilitators for data-sharing and resource implications for data acquisition on an annual basis, and variations in top-5 causes of SMM.Ethics and dissemination The study has been approved by the Mount Sinai and Hamilton Integrated Research Ethics Boards. The study findings will be presented at annual scientific meetings of the Society of Obstetricians and Gynaecologists of Canada, North American Society of Obstetric Medicine, and International Network of Obstetric Survey Systems and published in an open-access peer-reviewed Obstetrics and Gynaecology or General Internal Medicine journal.

Abstract Young women with chronic kidney disease (CKD) have disproportionately increased risk of cardiovascular mortality. Reduced anti‐Müllerian hormone (AMH) is linked to poor cardiovascular outcomes in the general population, but whether AMH is associated with increased cardiovascular risk in the high‐risk CKD population is unknown. This study examined the association between AMH and vascular function, validated markers of cardiovascular risk, in women with CKD. An exploratory cross‐sectional study was performed in 47 young women with CKD. Laboratory measurements of AMH were collected. Using standardized protocols, endothelial function was measured with brachial artery flow‐mediated dilation and hyperemic velocity time integral. Arterial stiffness was measured with aortic augmentation index and pulse wave velocity. Multivariate linear regression analyses were utilized to evaluate the association between AMH levels and each measure of vascular health. Forty women (36 ± 7 years) with non‐dialysis‐dependent CKD and 7 women (38 ± 6 years) with dialysis‐dependent CKD participated. AMH levels were inversely associated with age (p = 0.01) but not associated with eGFR (p = 0.59) or dialysis status (p = 0.97). AMH was associated with brachial artery flow‐mediated dilation (R2 = 0.21 [p = 0.03]) and aortic augmentation index (R2 = 0.20 [p = 0.04]) in the non‐dialysis‐dependent participants, and with aortic augmentation index in all participants (R2 = 0.18 [p = 0.03]). No association between AMH and any measure of vascular function was demonstrated in the dialysis‐dependent participants. AMH levels are associated with impaired vascular function in young women with CKD and may be an important marker of future cardiovascular risk. Further investigation into this female‐specific cardiovascular risk factor is warranted in this high‐risk population.

Data pooling from pre-existing multiple datasets can be useful to increase study sample size and statistical power to answer a research question. However, individual datasets may contain variables that measure the same construct differently, posing challenges for data pooling. Variable harmonization, an approach that can generate comparable datasets from heterogeneous sources, can address this issue in some circumstances. As an illustrative example, this paper describes the data harmonization strategies that helped generate comparable datasets across two Canadian pregnancy cohort studies– the All Our Families and the Alberta Pregnancy Outcomes and Nutrition. Variables were harmonized considering multiple features across the datasets: the construct measured; question asked/response options; the measurement scale used; the frequency of measurement; timing of measurement, and the data structure. Completely matching, partially matching, and completely un-matching variables across the datasets were determined based on these features. Variables that were an exact match were pooled as is. Partially matching variables were synchronized across the datasets considering the frequency of measurement, the timing of measurement, and response options. Variables that were completely unmatching could not be harmonized into a single variable. The variable harmonization strategies that were used to generate comparable cohort datasets for data pooling are applicable to other data sources. Future studies may employ or evaluate these strategies. Variable harmonization and pooling provide an opportunity to increase study power and the utility of existing data, permitting researchers to answer novel research questions in a statistically efficient, timely, and cost-efficient manner that could not be achieved using a single data source.

BackgroundIn June 2013, the city of Calgary, Alberta and surrounding areas sustained significant flooding which resulted in large scale evacuations and closure of businesses and schools. Floods can increase stress which may negatively impact perinatal outcomes and mental health, but previous research is inconsistent. The objectives of this study are to examine the impact of the flood on pregnancy health, birth outcomes and postpartum mental health.MethodsLinked administrative data from the province of Alberta were used. Outcomes included preterm birth, small for gestational age, a new diagnoses of preeclampsia or gestational hypertension, and a diagnosis of, or drug prescription for, depression or anxiety. Data were analyzed using a quasi-experimental difference in difference design, comparing flooded and non-flooded areas and in affected and unaffected time periods. Multivariable log binomial regression models were used to estimate risk ratios, adjusted for maternal age. Marginal probabilities for the difference in difference term were used to show the potential effect of the flood.ResultsParticipants included 18,266 nulliparous women for the pregnancy outcomes, and 26,956 women with infants for the mental health analysis. There were no effects for preterm birth (DID 0.00, CI: -0.02, 0.02), small for gestational age (DID 0.00, CI: -0.02, 0.02), or new cases of preeclampsia (DID 0.00, CI: -0.01, 0.01). There was a small increase in new cases of gestational hypertension (DID 0.02, CI: 0.01, 0.03) in flood affected areas. There were no differences in postpartum anxiety or depression prescriptions or diagnoses.ConclusionThe Calgary 2013 flood was associated with a minor increase in gestational hypertension and not other health outcomes. Universal prenatal care and magnitude of the disaster may have minimized impacts of the flood on pregnant women.

Background Existing association between mental disorders and suicidality is mostly based on cross- sectional studies, using clinical samples. Objective and methods We examined the patterns of association between mental disorders and subsequent suicide in a representative sample of the Canadian household population. This is a retrospective cohort study that used data from the Canadian Community Health Survey 2002 linked to the Death Database 2000-2011 and the Hospitalization Database 1999/2000-2012/2013) (N=27,000). Mental disorders (past-year major depressive episodes (MDE), bipolar disorders (BPD), anxiety disorders (AD), and substance-dependent (SD)) were diagnosed in the survey data using the Composite International Diagnostic Interview. Subsequent suicide events (deaths/hospitalizations for suicide attempts) were identified using ICD-10-CA codes. Time-to-event data were analyzed using competing-risk regression models, adjusting for age, sex, marital status, and educational attainment. Due to the violation of the proportional hazard assumption, the models were stratified into two strata. Sampling weights were used to ensure representation of the target population. Results Of 27,000 respondents, mental disorders were diagnosed in 15.0% respondents and 0.4% had suicide events. Each mental disorder was significantly associated with an increased risk of suicide. The strength of association between mental disorder and suicide weakened over-time for MDE, SD, but not for BPD and AD. For example, using the time-to-event cut-off 4-year, the hazard ratio (HR) for MDE was 6.02 (95% CI=2.65,13.68) in the first 4-year, whereas, it was 2.03 (95% CI=0.91,4.53) after 4-year. The HRs of suicide for BPD were 16.95 (95% CI=6.88,41.75) and 15.81 (95% CI=5.89,42.45) before and after 4-year. Conclusions/Implications Findings reflect improvement of suicide-risk over-time for people with MDE and SA and the persisting risk for people with BPD and AD. Our findings underscore the importance of early management of mental disorders for effective suicide prevention, and requirement of longer-term follow-up for people with BPD and AD.

ObjectiveThis study examined the association of anxiety alone, depression alone and the presence of both anxiety and depression with preterm birth (PTB) and further examined whether neighbourhood socioeconomic status (SES) modified this association.DesignCohort study using individual-level data from two community-based prospective pregnancy cohort studies (All Our Families; AOF) and Alberta Pregnancy Outcomes and Nutrition (APrON) and neighbourhood SES data from the 2011 Canadian census.SettingCalgary, Alberta, Canada.ParticipantsOverall, 5538 pregnant women who were 15 years old were enrolled in the cohort studies between 2008 and 2012. 3341 women participated in the AOF study and 2187 women participated in the APrON study, with 231 women participated in both studies. Women who participated in both studies were only counted once.Primary and secondary outcome measuresPTB was defined as delivery prior to 37 weeks of gestation. Depression was defined as an Edinburgh Postnatal Depression Scale (EPDS) score of ≥13, anxiety was defined as an EPDS-anxiety subscale score of ≥6, and the presence of both anxiety and depression was defined as meeting both anxiety and depression definitions.ResultsOverall, 7.3% of women delivered preterm infants. The presence of both anxiety and depression, but neither of these conditions alone, was significantly associated with PTB (OR 1.6, 95% CI 1.1 to 2.3) and had significant interaction with neighbourhood deprivation (p=0.004). The predicted probability of PTB for women with both anxiety and depression was 10.0%, which increased to 15.7% if they lived in the most deprived neighbourhoods and decreased to 1.4% if they lived in the least deprived neighbourhoods.ConclusionsEffects of anxiety and depression on risk of PTB differ depending on where women live. This understanding may guide the identification of women at increased risk for PTB and allocation of resources for early identification and management of anxiety and depression.

Introduction The International Methodology Consortium for Coded Health Information (IMeCCHI) is a collaboration of health services researchers who promote methodological advances in coded health information. The IMeCCHI-DATANETWORK initiative focuses on developing a multi-purpose distributed data infrastructure and common data model (CDM) to enable cross-border data sharing and international comparisons. Methods IMeCCHI consortium partners from six different countries – Canada, Denmark, Italy, New Zealand, South Korea, and Switzerland – used a questionnaire to describe their original databases which differ in size, structure, content and coding systems. To standardize these data, they agreed on a CDM and mapped their population-based databases to meet the CDM specifications. At the end of this process, local data had a more homogenous content and structure, which made them syntactically and semantically interoperable. Data transformation was performed using a common data management software called TheMatrix. Results The CDM encompasses four tables of structured data (person characteristics, hospitalizations, outpatient prescription medication and death), linked at the individual level through a person identifier. It can be used to answer research questions across countries using locally converted databases, which facilitates study replication in a distributed fashion. As a proof-of-concept study, an initial research question was addressed using an agreed protocol. Local data were transformed in csv files in the CDM structure and TheMatrix was tested to transform the standardized data from each partner into local analytical datasets. This allowed results to be shared between countries, whilst maintaining local control over each region’s data. Conclusion The IMeCCHI-DATANETWORK, a model of a distributed data network, demonstrated that it is feasible to analyze international data using standardized analytical methods that enable independent analyses by regions, without relocating datasets thereby protecting local confidentiality obligations. The distributed data infrastructure can produce results that can be generalized to several countries, while facilitating cross-border data sharing and international comparisons.

Abstract Background Cell-free DNA (cfDNA) screening has recently acquired tremendous attention, promising patients and healthcare providers a more accurate prenatal screen for aneuploidy than other current screening modalities. It is unclear how much knowledge regarding cfDNA screening obstetrical providers possess which has important implications for the quality and content of the informed consent patients receive. Methods A survey was designed to assess obstetrical provider knowledge and attitudes towards cfDNA screening and distributed online through the Society of Obstetricians & Gynecologists of Canada (SOGC). Chi-squared tests were used to detect differences in knowledge and attitudes between groups. Results 207 respondents completed the survey, composed of 60.6% Obstetricians/Gynecologists (OB/GYN), 15.4% Maternal Fetal Medicine (MFM) specialists, 16.5% General Practitioners (GP), and 7.5% Midwives (MW). MFM demonstrated a significant trend of being most knowledgeable about cfDNA screening followed by OB/GYN, GP, and lastly MW in almost all aspects of cfDNA screening. All groups demonstrated an overall positive attitude towards cfDNA screening; however, OB/GYN and MFM demonstrated a significantly more positive attitude than GP and MW. Despite not yet being a diagnostic test, 19.4% of GP would offer termination of pregnancy immediately following a positive cfDNA screen result compared to none of the MFM and only few OB/GYN or MW. Conclusions We have demonstrated that different types of obstetrical providers possess varying amounts of knowledge regarding cfDNA screening with MFM currently having greater knowledge to all other groups. All obstetrical providers must have adequate prenatal screening understanding so that we can embrace the benefits of this novel and promising technology while protecting the integrity of the informed consent process.

Abstract Background Integrative health care (IHC) is an innovative approach to health care delivery. There is increasing focus on and demand for the evaluation of IHC practices. To ensure such evaluations capture their full scope, a clear understanding of the types of outcomes relevant to an IHC approach is needed. The objective was to describe the health domains and health outcomes relevant to IHC practices in Canada. Methods An online survey of Canadian IHC clinics. Survey questions were informed by the IN-CAM Health Outcomes Database. Descriptive statistics were used to summarize the data. Chi square tests were used to compare responses between clinic types and patient groups served. Results Surveys were completed by 21 clinics (response rate: 50%). Physical, psychological, social, individualized and holistic were identified as applicable health domains by more than 90% of the clinics. Spiritual domain was the least relevant (70% of clinics). A number of relevant outcomes within each domain were identified. A core set of outcomes were identified and included: fatigue, anxiety, stress, and patient-provider relationship, and quality of life. Clinics with primarily conventional health practitioners were less likely to address overall well-being (p = 0.04), while clinics that provided care to a specialized patient population (i.e. cancer patients) or a mix of general and specialized patients were less likely to address religious practices (p = 0.04) or spiritual experiences (p = 0.007). Conclusions Outcomes across health domains should be considered in the evaluation of IHC models to generate an understanding of the full scope of effectiveness of IHC approaches. The core set of outcomes identified may facilitate this task. Ethics approval (Ethics ID REB14-0495) was received from the Conjoint Health Research Ethics Board at the University of Calgary.

Abstract Background The prevalence of menopause in women with or at risk of chronic kidney disease is increasing globally. Although international guidelines on menopause recommend the use of postmenopausal hormone therapy with or without selective estrogen receptor modulators for control of vasomotor symptoms, the effects of these treatments on kidney function and albuminuria are unclear. Furthermore, women with chronic kidney disease are at significantly increased risk of venous thromboembolism and malignancy, well-documented adverse effects of postmenopausal hormone therapy. Our study aims to establish the effect of these treatments on kidney function and albuminuria in women, as well as determine the safety of these treatments in the chronic kidney disease population. Methods We will conduct a systematic review and meta-analysis addressing the effect and safety of postmenopausal hormone therapy and selective estrogen receptor modulators on kidney outcomes in women. We plan to search for published (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), tables of contents of relevant journals) and unpublished (ongoing studies, conference proceedings) studies in all languages examining the effect of postmenopausal hormone therapy, including selective estrogen receptor modulators, on kidney function and albuminuria, as well as the risk of adverse outcomes of these treatments in women with chronic kidney disease. Two independent investigators will screen identified abstracts and select studies that examine the effect of postmenopausal hormone therapy and selective estrogen receptor modulators on kidney outcomes in the general population or adverse outcomes in the chronic kidney disease population. Data on study population, intervention, outcomes, as well as study quality and risk of bias will be independently extracted from each eligible study. Along with descriptive presentation of data, outcome measures will be presented as meta-analyses using a random effects model. Planned subgroup analyses will be completed, and meta-regression will be performed if significant heterogeneity is noted. Discussion By examining the effects of postmenopausal hormone therapy and selective estrogen receptor modulators on kidney function and albuminuria, the results of this systematic review and meta-analysis will inform management of postmenopausal women in the general population. Furthermore, it will evaluate the safety, including the risks of known adverse outcomes of postmenopausal hormone therapy and selective estrogen receptor modulators, in the already vulnerable chronic kidney disease population. Systematic review registration PROSPERO CRD42016050651

Abstract Background There are conflicting results in the literature on the impact of chorioamnionitis on neonatal respiratory morbidities. However, most studies are based on small clinical samples and fail to account for the competing risk of perinatal death. This study aimed to determine whether chorioamnionitis affects the incidence of respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD) after accounting for the increased risk of death. Methods Retrospective cohort study using linked birth and infant death registration and hospitalization records from Washington State between 2002 and 2011 (n = 763,671 singleton infants and n = 56,537 singleton preterm infants). Logistic regression models based on the traditional and fetuses-at-risk approaches were used to model two composite outcomes namely RDS and perinatal death and BPD and perinatal death. Confounders adjusted for in the models included maternal age, race, diabetes, hypertension, antenatal corticosteroids, mode of delivery and infant sex. Results While models using the traditional approach found a significant association only between chorioamnionitis and composite BPD and perinatal death (OR = 1.23, 95% CI: 1.01–1.50); using the fetuses-at-risk approach, there was a significant association between chorioamnionitis and both composite outcomes (RDS and perinatal death OR = 2.74, 2.50–3.01; BPD and perinatal death OR = 5.18, 95% CI: 4.39–6.11). Conclusion The fetuses-at-risk approach models the causal impact of chorioamnionitis on the development of the fetal lung and shows an increased risk of RDS, BPD and perinatal death associated with such maternal infection.

There is international interest in monitoring severe events in the obstetrical population, commonly referred to as maternal near miss or severe maternal morbidity. These events can have significant consequences for individuals in this population and further study can inform practices to reduce both maternal morbidity and mortality. Numerous surveillance systems exist but we lack a standardized approach. Given the current inconsistencies and the importance in monitoring these events, this study aimed to identify and compare commonly used surveillance methods. In June 2018, we systematically searched MEDLINE, EMBASE, and CINAHL using terms related to monitoring/surveillance and maternal near miss/severe maternal morbidity. We included papers that used at least three indicators to monitor for these events and collected data on specific surveillance methods. We calculated the rate of maternal near miss/severe maternal morbidity in hospitalization data obtained from the 2016 US National Inpatient Sample using five common surveillance methods. Of 18,832 abstracts, 178 papers were included in our review. 198 indicators were used in studies included in our review; 71.2% (n = 141) of these were used in 50% of studies included in our review. Eclampsia was the only indicator that was assessed in >80% of included studies. The rate of these events in American hospitalization data varied depending on the criteria used, ranging from 5.07% (95% CI = 5.02, 5.11) with the Centers for Disease Control criteria and 7.85% (95% CI = 7.79, 7.91) using the Canadian Perinatal Surveillance System. Our review highlights inconsistencies in monitoring practices within and between developed and developing countries. Given the wide variation in monitoring approaches observed and the likely contributing factors for these differences, it may be more feasible for clinical and academic efforts to focus on standardizing approaches in developed and developing countries independently at this time. PROSPERO Registration: CRD42018096858.

Affecting 10–15% of women, postpartum depression (PPD) can be debilitating and costly. While early identification has the potential to improve timely care, recommendations regarding the implementation of routine screening are inconsistent. In Alberta, screening is completed using the Edinburgh Postnatal Depression Scale during public health well child clinic visits. The objective of this study was to examine the effectiveness of screening in identifying, diagnosing and treating women at increased risk for PPD over the first year postpartum, compared to those unscreened. The All Our Families prospective pregnancy cohort was linked to public health, inpatient, outpatient, physician claims and community pharmaceutical data over the first year postpartum. Descriptive statistics and bivariate analyses examined differences in sample characteristics and PPD and non-PPD related utilization by screening category. Odds ratios and 95% confidence intervals for PPD diagnosis and mental health drugs dispensed were generated using crude and multivariable logistic regression models. Within our sample, 87% of the eligible population were screened, with 3% receiving a high-risk score, and 13% were unscreened. Compared to those unscreened, women screened high-risk had higher odds of being diagnosed with PPD (OR: 3.88, 95% CI: 2.18–6.92) and women screened low/moderate-risk had reduced odds of receiving a diagnosis (OR: 0.51, 95% CI: 0.35–0.74). High-risk women had an increased likelihood of diagnosis, higher PPD-related utilization and drugs dispensed compared to those unscreened. This information suggests that screening was effective at streamlining resources in Alberta. Future work should focus on evaluating the cost-effectiveness of PPD screening. Keywords: Perinatal depression, Screening, Public health, Evaluation

Introduction Vaccinating pregnant patients for neonatal protection needs to be integrated into prenatal care as new vaccines emerge. Uptake of influenza vaccine, universally recommended in pregnancy, is low. Immunization was offered and administered to pregnant women at point of care (POC) during two flu seasons at an urban tertiary care center. Objectives and Approach Primary objective is to determine if POC impacts immunization rate during flu season among a cohort of pregnant women by location and gestational age. Secondary objectives are to examine the pattern of influenza-like illnesses (ILI) among vaccinated and unvaccinated women, and to describe pilot outcomes of POC. Four consecutive influenza seasons (2014/2015, 2015/2016, 2016/2017, 2017/2018) will be examined using seven databases: a) Clinibase, b) National Ambulatory Care Reporting System; C) Discharge Abstract Database; d) Physician Claims; e) Alberta Perinatal Health Program; f) Calgary Zone Public Health; and g) Pharmaceutical Information Network. Outcomes will be examined descriptively using frequencies and proportions. Results Based on the preliminary analysis, approximately 10, 000 visits among 2,500 women occurred during each flu season at the four obstetric care locations: two outpatient clinics and two inpatient units. The proportion of pregnant women who received the flu vaccine ranged from 15-21% during the first three flu seasons. Majority of the women received the vaccine at the flu campaigns (range 48-67%), followed by pharmacy (20-32%). For the 2017-2018 season, year to date uptake rates in outpatient clinics are significantly higher. Final results on additional outcomes will be available by September 2018. Conclusion/Implications In completing this study, we hope to better understand the patterns of immunization uptake in pregnancy by place of immunization and gestational age, i.e. identifying optimal “window of opportunity”. Results will inform the infrastructure needed to collect data on vaccines administered during pregnancy and linkage to maternal and infant outcomes.

Introduction Pregnant women are often concerned about the impact of antidepressant medication use on their pregnancy, such as congenital abnormalities. This concern may vary in a way that depends on the class of antidepressant medication prescribed. Objectives and Approach This study examined the rate of adherence and persistence to antidepressants based on the class of antidepressants prescribed during pregnancy This is a retrospective cohort study using population-based administrative data in Alberta– linking delivery record, hospitalization data, physician claims data, emergency department data, and prescription medication data. The eligible study population included women with depression who gave birth between 2012-2015, and were adherent (medication possession ratio ≥80%) to ≥ 2 consecutive antidepressant prescriptions during the preconception year (n=1,865). The rates of adherence and persistence (prescription refill gap ≤30 days) were calculated by medication class and were compared using chi-square tests. Results During pregnancy, 834 (44.7%) women completely stopped taking antidepressants. Among those taking antidepressants, the overall rate of adherence was 62.6% (95% CI: 59.4%, 65.7%). The rate differed significantly by medication class (p

Introduction Preterm birth (birth

Introduction Medical therapy to maintain disease remission is important in pregnant women with inflammatory bowel disease (IBD), as disease flares can predispose adverse materno-fetal outcomes. However, women with IBD are more concerned about medication exposure on their newborn during pregnancy, and often discontinue their medications. Objectives and Approach We assessed the rate of disease flare on medication adherence pattern during pregnancy for women with IBD. Validated case definition was used to identify women with IBD from the Albertan’s hospitalization, emergency room, and physician claims databases (2010-2016). Pharmaceutical Information Network provided the dispensed medications. Adherence to medication was defined by medical possession ratio (MPR)≥0.8. Women with two consecutive prescriptions and MPR≥0.8 during pre-conception were included. Disease flare was defined by ≥1 hospitalization or emergency visit for IBD, or ≥1 prescription for steroids/rectal therapy. Chi-square tests and log binomial regression were used; covariates included age, drug class, and IBD subtypes. Results Of the 370 women identified with IBD, 170 (45.9%) women were adherent to maintenance IBD medications in the one year prior to pregnancy. During pregnancy, 47 (27.6%; 95% CI: 21.4% to 34.9%) women, who demonstrated adherence in the pre-conception period, discontinued or were not adherent to their IBD medications, and 67 (39.4%; 95% CI: 32.3% to 47.0%) women had a disease flare during pregnancy. There was no significant difference between adherence to medication during pregnancy and a disease flare during pregnancy (p=0.38). In comparing women who were not adherent or discontinued their medication to those that were adherent, the adjusted relative risk ratio for a disease flare during pregnancy was 1.22 (95% CI: 0.81 to 2.04). Conclusion/Implications The rate of disease flare during pregnancy was not significantly different for women with IBD that were adherent or not-adherent to their IBD medications during pregnancy. Future analysis will assess the rate of disease flare on medication adherence pattern prior to pregnancy.

OBJECTIVE:To evaluate the performance of the INTERGROWTH-21st Project newborn standard vis-a-vis the current Canadian birth weight-for-gestational age reference. METHODS:All hospital-based singleton live births in Canada (excluding Quebec) between 2002 and 2012 with a gestational age between 33 and 42 weeks were included using information obtained from the Canadian Institute for Health Information. Small- and large-for gestational age centile categories of the INTERGROWTH standard and Canadian reference were contrasted in terms of frequency distributions and rates of composite neonatal morbidity/mortality. RESULTS:Among 2,753,817 singleton live births, 0.87% and 9.63% were 97th centile, respectively, of the INTERGROWTH standard, while 2.27% and 3.55% were 97th centile, respectively, of the Canadian reference. Infants 97th centile had a composite neonatal morbidity/mortality rate of 46.4 and 12.9 per 1,000 live births, respectively, under the INTERGROWTH standard and 30.9 and 16.6 per 1,000 live births, respectively, under the Canadian reference. The INTERGROWTH standard 97th centile categories had detection rates of 3.14% and 9.74%, respectively, for composite neonatal morbidity/ mortality compared with 5.48% and 4.60%, respectively for the Canadian reference. Similar patterns were evident in high- and low-risk subpopulations. CONCLUSIONS:The centile distribution of the INTERGROWTH newborn standard is left shifted compared with the Canadian reference, and this shift alters the frequencies and neonatal morbidity/mortality rates associated with specific centile categories. Further outcome-based research is required for defining abnormal growth categories before the INTERGROWTH newborn standard can be used.