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Breastfeeding provides infants with nutrients required for optimal growth and development. We aimed to examine breastfeeding practices and supports that promote exclusive breastfeeding during the birth hospital stay among birthing parents with physical disabilities, sensory disabilities, intellectual or developmental disabilities, and multiple disabilities compared with those without a disability.This population-based cohort study was done in Ontario, Canada. We accessed and analysed health administrative data from ICES and the Better Outcomes RegistryNetwork. We included all birthing parents aged 15-49 years who had a singleton livebirth between April 1, 2012, and March 31, 2018. The study outcomes were breastfeeding practices and supports that promoted exclusive breastfeeding during the birth hospital stay, conceptualised based on WHO-UNICEF Baby Friendly Hospital Initiative guidelines. Individuals with a physical disability, sensory disability, intellectual or developmental disability, or two or more (multiple) disabilities, identified using diagnostic algorithms, were compared with individuals without disabilities on the opportunity to initiate breastfeeding, in-hospital breastfeeding, exclusive breastfeeding at hospital discharge, skin-to-skin contact, and provision of breastfeeding assistance. Relative risks (RRs) were estimated using modified Poisson regression.Our cohort included 634 111 birthing parents, of whom 54 476 (8·6%) had a physical disability, 19 227 (3·0%) had a sensory disability, 1048 (0·2%) had an intellectual or developmental disability, 4050 (0·6%) had multiple disabilities, and 555 310 (87·6%) had no disability. Individuals with intellectual or developmental disabilities were less likely than those without a disability to have an opportunity to initiate breastfeeding (adjusted RR 0·82, 95% CI 0·76-0·88), any in-hospital breastfeeding (0·85, 0·81-0·88), exclusive breastfeeding at hospital discharge (0·73, 0·67-0·79), skin-to-skin contact (0·90, 0·87-0·94), and breastfeeding assistance (0·85, 0·79-0·91). Those with multiple disabilities were less likely to have an opportunity to initiate breastfeeding (0·93, 0·91-0·96), any in-hospital breastfeeding (0·93, 0·92-0·95), exclusive breastfeeding at hospital discharge (0·90, 0·87-0·93), skin-to-skin contact (0·93, 0·91-0·95), and breastfeeding assistance (0·95, 0·92-0·98). Differences for individuals with a physical or sensory disability only were mostly non-significant.Our findings show disparities in breastfeeding outcomes between individuals without a disability and individuals with intellectual or developmental disabilities or multiple disabilities, but not individuals with physical or sensory disabilities. There is a need for further research on the factors that contribute to breastfeeding intentions, practices, and supports in people with intellectual or developmental disabilities and multiple disabilities, especially factors that affect breastfeeding decision making.National Institutes of Health and the Canada Research Chairs Program.

Background and Hypothesis Maternal schizophrenia heightens the risk for certain perinatal complications, yet it is not known to what degree future childhood chronic health conditions (Childhood-CC) might arise. Study Design This population-based cohort study using health administrative data from Ontario, Canada (1995–2018) compared 5066 children of mothers with schizophrenia to 25 324 children of mothers without schizophrenia, propensity-matched on birth-year, maternal age, parity, immigrant status, income, region of residence, and maternal medical and psychiatric conditions other than schizophrenia. Cox proportional hazard models generated hazard ratios (HR) and 95% confidence intervals (CI) for incident Childhood-CCs, and all-cause mortality, up to age 19 years. Study Results Six hundred and fifty-six children exposed to maternal schizophrenia developed a Childhood-CC (20.5/1000 person-years) vs. 2872 unexposed children (17.1/1000 person-years)—an HR of 1.18, 95% CI 1.08–1.28. Corresponding rates were 3.3 vs. 1.9/1000 person-years (1.77, 1.44–2.18) for mental health Childhood-CC, and 18.0 vs. 15.7/1000 person-years (1.13, 1.04–1.24) for non-mental health Childhood-CC. All-cause mortality rates were 1.2 vs. 0.8/1000 person-years (1.34, 0.96–1.89). Risk for children exposed to maternal schizophrenia was similar whether or not children were discharged to social service care. From age 1 year, risk was greater for children whose mothers were diagnosed with schizophrenia prior to pregnancy than for children whose mothers were diagnosed with schizophrenia postnatally. Conclusions A child exposed to maternal schizophrenia is at elevated risk of chronic health conditions including mental and physical subtypes. Future research should examine what explains the increased risk particularly for physical health conditions, and what preventive and treatment efforts are needed for these children.

Indigenous peoples experience high rates of suicide from historical and ongoing colonization. This systematic review examines the effectiveness, involvement of Indigenous peoples, and cultural content of interventions addressing suicide among Indigenous adults in Canada, the United States, New Zealand, and Australia. Through a systematic search of scholarly articles and grey literature, 10 articles met the inclusion criteria. In nine studies, Indigenous people made decisions at the study design level and implemented and delivered research activities, and eight studies included cultural content. There were statistically significant reductions in suicide outcomes in four studies, and in self-harm and hopelessness in two studies each. Study quality was largely weak ( n = 9) or moderate ( n = 1). There is a paucity of high-quality data on interventions addressing suicide among Indigenous adults and strengthened reporting of health research involving Indigenous peoples in interventions.

Study background Despite the growing understanding of preconception care, numerous barriers to its delivery still exist, including a lack of evidence-based, accessible screening tools. Purpose To validate a new digital Preconception Health Assessment Tool (PreCHAT) against the current best practice, physician-delivered tool in Ontario, Canada, and explore how PreCHAT’s design impacts its risk identification abilities relative to the comparison tool. Methods A criterion validation study was conducted with 53 female participants aged 18–44 years. Participants completed both tools in a controlled setting. PreCHAT was completed on a tablet individually by participants, while the comparison tool was administered by a physician. Three physicians administered the comparison tool. Measures of strength of agreement between PreCHAT and the comparison tool were calculated using percent agreement, Cohen's Kappa, and prevalence-adjusted and biased-adjusted kappa (PABAK). Results PreCHAT identified 135 individual risk factors, while the comparison tool identified 102. Both tools shared the same 14 domains of preconception care and 88 risk factors; of the 88 risk factors, PreCHAT identified an average of 3.42 (p Conclusions This study suggests that PreCHAT is valid against the current best practice tool and is broader in its risk identification among individuals of reproductive age. PreCHAT's patient-facing, digital, EMR-integrated design may offer unique benefits to providers and patients. PreCHAT offers providers an innovative approach to deliver preconception care and may positively impact reproductive, maternal, and child health.

Emergency department visits for a psychiatric reason in the post-partum period represent an acute need for mental health care at a crucial time, but little is known about the extent of timely outpatient follow-up after these visits or how individual and intersecting social determinants of health influence this outcome. This study aimed to examine outpatient mental health care follow-up by a physician in the 30 days after an individual attended the emergency department for a psychiatric reason in the post-partum period and understand how social determinants of health affect who receives follow-up care.In this population-based cohort study, routinely collected health data from Ontario, Canada were accessed through ICES to identify all post-partum individuals whose sex was listed as female on their health card and who had attended an emergency department in Ontario before the COVID-19 pandemic for a psychiatric reason. Individuals admitted to hospital at the time of the emergency department visit, who died during the visit, or who left without being seen were excluded from the study. Ethnicity data for individuals were not collected. The primary outcome was the proportion of individuals with any outpatient physician (psychiatrist or family physician) visit for a mental health reason within 30 days of the index emergency department visit. Family physician mental health visits were identified using a validated algorithm for Ontario Health Insurance Plan-billed visits and mental health diagnostic codes for community health centre visits. We examined the associations between social determinants of health (age, neighbourhood income, community size, immigration, neighbourhood ethnic diversity) and who received an outpatient mental health visit. We used modified Poisson regression adjusting for the other social determinants of health, clinical, and health services characteristics to examine independent associations with follow-up, and conditional inference trees to explore how social determinants of health intersect with each other and with clinical and health services characteristics in relation to follow-up.We analysed data collected between April 1, 2008, and March 10, 2020, after exclusions we identified 12 158 people who had attended the emergency department for a psychiatric reason in the post-partum period (mean age 26·9 years [SD 6·2]; range 13-47); 9848 individuals lived in an urban area, among these 1518 (15·5%) were immigrants and 2587 (26·3%) lived in areas with high ethnic diversity. 5442 (44·8%) of 12 158 individuals received 30-day follow-up. In modified Poisson regression models, younger age, lower neighbourhood income, smaller community size, and being an immigrant were associated with a lower likelihood of follow-up. In the CTREE, similar variables were important, with several intersections between social determinants of health and between social determinants of health and other variables.Fewer than half of emergency department visits for a psychiatric reason in the post-partum period were followed by timely outpatient care, with social-determinants-of-health-based disparities in access to care. Improvements in equitable access to post-emergency department mental health care are urgently needed in this high-risk post-partum population.Department of Psychiatry, University of Toronto; Canadian Institutes of Health Research.

Objective: To assess the effects of psychological, psychosocial, educational and alternative interventions on mental health outcomes of Indigenous adult populations in Australia, Canada, New Zealand and the United States and the Indigenous involvement and content in each study. Methods: We systematically searched databases, key journals and gray literature, for records until June 2020. Eligible studies were in English or French and examined the impact of interventions on mental health outcomes including anxiety disorders, posttraumatic stress disorder, depression, psychological distress or stress for Indigenous adults (⩾16 years). Data were extracted using a modified Cochrane Data Extraction Form and the Template for Intervention Description and Replication. Quality was evaluated using the Effective Public Health Practice Project quality assessment form. Results: In total, 21 studies were eligible, comprising 8 randomized controlled trials, 10 single-group pre–post studies and 3 pre–post studies with comparison groups. Twenty studies had Indigenous individuals or organizations involved in some decision-making capacity, though extent of involvement varied widely. In total, 9 studies were rated moderate and 12 weak in the Effective Public Health Practice Project quality assessment. Eight studies measuring depression, three measuring posttraumatic stress disorder, three measuring psychological distress and two measuring stress showed statistically significant improvements following the intervention. Conclusion: A wide range of interventions demonstrated mental health improvements. However, it is difficult to draw generalizable conclusions on intervention effectiveness, given heterogeneity among studies. Studies should employ a thorough assessment of the Indigenous involvement and content of their interventions for reporting and for critical consideration of the implications of their research and whether they address Indigenous determinants of mental health.

Background: Chronic disease is associated with increased risk of postpartum mental illness, but the mechanisms underlying this association are unclear. Our aim was to explore the mediating role of ...

Introduction This study examines prenatal care adequacy among women with physical, sensory, and intellectual/developmental disabilities, compared with that among women without disabilities. Methods A population-based cohort study using linked health administrative data in Ontario, Canada was completed. The study population comprised women with physical (n=83,752), sensory (n=25,685), intellectual/developmental (n=1,219), and multiple (n=4,966) disabilities and women without disabilities (n=953,766), with a birth in 2003–2017. Analyses were conducted in 2020. Women with disabilities were identified using algorithms applied to healthcare encounters before conception. The main outcome was prenatal care adequacy, measured using the Revised Graduated Prenatal Care Utilization Index. Multivariable nominal logistic regression was used to compute the AORs and 95% CIs for no, inadequate, and intensive (versus adequate) care comparing each disability group with women without disabilities, adjusting for sociodemographic and health characteristics. Results Women with physical disabilities, compared with those without disabilities, had increased odds of intensive prenatal care (AOR=1.22, 95% CI=1.19, 1.24) and decreased odds of no prenatal care (AOR=0.94, 95% CI=0.89, 0.99) versus adequate care. Women with sensory disabilities had increased odds of intensive (AOR=1.11, 95% CI=1.08, 1.14), inadequate (AOR=1.06, 95% CI=1.02, 1.09), and no (AOR=1.24, 95% CI=1.14, 1.35) prenatal care. Women with intellectual/developmental disabilities had increased odds of inadequate (AOR=1.25, 95% CI=1.08, 1.44) and no (AOR=1.64, 95% CI=1.16, 2.34) prenatal care. Women with multiple disabilities had increased odds of intensive (AOR=1.41, 95% CI=1.32, 1.51) and inadequate (AOR=1.14, 95% CI=1.05, 1.22) prenatal care. Conclusions There are variations in prenatal care adequacy by maternal disability status. Disparities in prenatal care access for women with disabilities, particularly those with intellectual/developmental disabilities, need to be addressed.

To determine the prevalence of comorbid depression and anxiety symptoms in fathers and investigate the predictors for comorbidity during the first- and second-year following birth.In a longitudinal Canadian study, couples were recruited within 3 weeks of childbirth. Fathers completed a survey after the birth of their child followed by questionnaires at 3, 6, 9, 12, 18, and 24 months postpartum on paternal depression and anxiety symptoms and potential risk factors. Sequential logistic regression was used for analysis.Of the 3217 enrolled fathers, 2544 (79.08%) provided data for at least one time point during the first year postpartum and 2442 (75.29%) in the second year. Overall, 569 fathers (22.4%) had comorbid depression and anxiety symptoms at some point during the first year postpartum (2.2% at baseline to 8.9% at 6 months), and 323 fathers (13.2%) had comorbidity at some point during their second year postpartum (8.1% at 18 months and 8.6% at 24 months). Strongest risk factors associated with paternal comorbidity were poor or fair perceived health at 4 weeks postpartum, depression before pregnancy, anxiety in the current pregnancy, significant adverse childhood experiences, positive ADHD screen, and victim of intimate partner violence.High rates of comorbidity among fathers in the first 2 years postpartum demonstrate the importance of perinatal mental health management at a family level. The identification of important modifiable comorbidity risk factors highlights areas for further research and the development of interventions to support paternal mental health to optimize child and family outcomes.

Introduction Despite increased attention on severe maternal morbidity and maternal mortality, scant research exists on adverse maternal outcomes in women with disabilities. This study compares the rates of severe maternal morbidity and maternal mortality in women with and without intellectual and developmental disabilities. Methods This study used 2004–2017 Healthcare Cost and Utilization Project Nationwide Inpatient Sample data. Analyses were conducted in 2019‒2020. The risk of severe maternal morbidity with and without blood transfusion and maternal mortality during delivery among women with and without intellectual and developmental disabilities were compared using modified Poisson regression analysis. Results This study identified 32,324 deliveries to women with intellectual and developmental disabilities. Per 10,000 deliveries, 566 deliveries with severe maternal morbidity occurred in women with intellectual and developmental disabilities compared with 239 in women without intellectual and developmental disabilities. Women with intellectual and developmental disabilities had greater risk of both severe maternal morbidity (risk ratio=2.36, 95% CI=2.06, 2.69) and nontransfusion severe maternal morbidity (risk ratio=2.95, 95% CI=2.42, 3.61) in unadjusted analyses, which was mitigated in adjusted analyses for sociodemographic characteristics (risk ratio=1.74, 95% CI=1.47, 2.06; risk ratio=1.85, 95% CI=1.42, 2.41) and the expanded obstetric comorbidity index (risk ratio=1.23, 95% CI=1.04, 1.44; risk ratio=1.31, 95% CI=1.02, 1.68). The unadjusted incidence of maternal mortality in women with intellectual and developmental disabilities was 284 per 100,000 deliveries, nearly 4-fold higher than in women without intellectual and developmental disabilities (69 per 100,000 deliveries; risk ratio=4.07, 95% CI=2.04, 8.12), and the risk remained almost 3-fold higher after adjustment for sociodemographic characteristics (risk ratio=2.86, 95% CI=1.30, 6.29) and the expanded obstetric comorbidity index (risk ratio=2.30, 95% CI=1.05, 5.29). Conclusions Women with intellectual and developmental disabilities are at increased risk of severe maternal morbidity and maternal mortality. These findings underscore the need for enhanced monitoring of the needs and maternal outcomes of women with intellectual and developmental disabilities in efforts to improve maternal health.

Hilary K Brown,1– 5 Andrew Wilton,5 Ning Liu,5 Joel G Ray,5,6 Cindy-Lee Dennis,6,7 Simone N Vigod3– 5 1Department of Health & Society, University of Toronto Scarborough, Toronto, ON, Canada; 2Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; 3Department of Psychiatry, University of Toronto, Toronto, ON, Canada; 4Women’s College Research Institute, Women’s College Hospital, Toronto, ON, Canada; 5ICES, Toronto, ON, Canada; 6Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada; 7Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, CanadaCorrespondence: Hilary K BrownDepartment of Health & Society, University of Toronto Scarborough, 1265 Military Trail, Toronto, ON, M1C 1A4, CanadaTel +1 416 208 2239Email hk.brown@utoronto.caBackground: Studies have demonstrated elevated risk for autoimmune disease associated with perinatal mental illness, but the extent to which this risk is specific to mental illness arising perinatally, and not mental illness generally, is unknown. Our objective was to compare the risk of autoimmune disease in women with mental illness arising within the perinatal period to (1) women with mental illness arising outside the perinatal period and (2) women who did not develop mental illness.Methods: We conducted a population-based matched cohort study of women aged 15– 49 years with no history of mental illness or autoimmune disease in Ontario, Canada, 1998– 2018. The exposed, 60,701 women with mental illness arising between conception and 365 days postpartum were propensity score-matched to (1) 264,864 women with mental illness arising non-perinatally and (2) 469,164 women who did not develop mental illness. Hazard ratios (HR) for autoimmune disease were generated using Cox proportional hazards models.Results: The incidence of autoimmune disease was similar among women with mental illness arising perinatally compared to those with mental illness arising non-perinatally (138.4 vs 140.7 per 100,000 person-years; HR 0.98, 95% CI 0.92– 1.05), and elevated among women with mental illness arising perinatally compared to those who did not develop mental illness (138.4 vs 88.9 per 100,000 person-years; HR 1.54, 95% CI 1.44– 1.64). The HR for the latter comparison was more pronounced for autoimmune disease with brain-reactive antibodies than other autoimmune disease.Conclusion: Perinatal mental illness is associated with increased risk of autoimmune disease that is no different than that of mental illness arising non-perinatally. Women with mental illness, regardless of the timing of onset, could benefit from early detection of autoimmune disease.Keywords: autoimmune diseases, cohort studies, mental disorders, women’s health

Despite the importance of contraception for pregnancy planning in females with chronic conditions, little is known about contraception use in those with two or more chronic conditions-i.e., multimorbidity. We examined contraception use among females with multimorbidity, one chronic condition, and no identified chronic conditions.We used data from the 2015 to 2016 Canadian Community Health Survey on 15 to 49-year-old females at risk of unintended pregnancy (n = 12,741), comparing females with ≥2 chronic conditions (21.3%) and one chronic condition (27.7%) to those with no identified chronic conditions (51.0%). We used modified Poisson regression to derive adjusted prevalence ratios (aPR) for any contraception vs no contraception, and multinomial logistic regression to derive adjusted odds ratios (aOR) for highly effective, moderately effective, and no contraception vs less effective contraception.Compared to females with no identified chronic conditions, those with multimorbidity were less likely to use any contraception (aPR 0.93, 95% CI 0.89 - 0.98). Females with multimorbidity were more likely than those with no identified chronic conditions to use no contraception (aOR 1.29, 95% CI 1.13 - 1.46), with little to no difference in the use of highly (aOR 1.08, 95% CI 0.91 - 1.29) or moderately effective contraception (aOR 0.98, 95% CI 0.86 - 1.13), vs less effective contraception. There were no differences between females with one chronic condition and no identified chronic conditions.The lower overall rate of contraception use in females with multimorbidity reflects a need for more attention to family planning in this population, with prompt and convenient access to highly effective options.Females with multimorbidity were less likely than those with no identified chronic conditions to use any contraception, and no more likely to use highly or moderately effective versus less effective contraception. Individuals with multimorbidity could benefit from attention to family planning, with prompt and convenient access to highly effective options.

Background The effect of being born late preterm (34-36 weeks gestation) on cardiometabolic outcomes across the life course is unclear. Objectives To systematically review the association between being born late preterm (spontaneous or indicated), compared to the term and cardiometabolic outcomes in children and adults. Data sources EMBASE(Ovid), MEDLINE(Ovid), CINAHL. Study selection and data extraction Observational studies up to July 2021 were included. Study characteristics, gestational age, cardiometabolic outcomes, risk ratios (RRs), odds ratios (ORs), hazard ratios (HRs), mean differences and 95% confidence intervals (CIs) were extracted. Synthesis We pooled converted RRs using random-effects meta-analyses for diabetes, hypertension, ischemic heart disease (IHD) and body mass index (BMI) with subgroups for children and adults. The risk of bias was assessed using the Newcastle-Ottawa scale and certainty of the evidence was assessed using the grading of recommendations, assessment, development and evaluation (GRADE) approach. Results Forty-one studies were included (41,203,468 total participants; median: 5.0% late preterm). Late preterm birth was associated with increased diabetes (RR 1.24, 95% CI 1.17, 1.32; nine studies; n = 6,056,511; incidence 0.9%; I2 51%; low certainty) and hypertension (RR 1.21, 95% CI 1.13, 1.30; 11 studies; n = 3,983,141; incidence 3.4%; I2 64%; low certainty) in children and adults combined. Late preterm birth was associated with decreased BMI z-scores in children (standard mean difference -0.38; 95% CI -0.67, -0.09; five studies; n = 32,602; proportion late preterm 8.3%; I2 96%; very low certainty). There was insufficient evidence that late preterm birth was associated with increased IHD risk in adults (HR 1.20, 95% CI 0.89, 1.62; four studies; n = 2,706,806; incidence 0.3%; I2 87%; very low certainty). Conclusions Late preterm birth was associated with an increased risk of diabetes and hypertension. The certainty of the evidence was low or very low. Inconsistencies in late preterm and term definitions, confounding variables and outcome age limited the comparability of studies.

Background Accessible and quality care during the perinatal period is critical for optimal maternal and neonatal health. Using the socio-ecological model, the purpose of this study was to explore barriers and facilitators that shape the perinatal care experiences of people with intellectual and/or developmental disabilities (IDD). Methods Semi-structured interviews were conducted with 10 individuals with IDD in Ontario, Canada, who had given birth within the past 5 years. Interviews focused on care experiences before, during, and after pregnancy. Data were analyzed using a directed content analysis approach, and the socio-ecological model guided analysis. Results Barriers at the societal (e.g., cultural norms of motherhood), policy/institutional (e.g., child protection policies and practices), interpersonal (e.g., inadequate formal and informal support), and intrapersonal levels (e.g., internalized stigma) contributed to participants having negative perinatal care experiences. Conversely, we identified facilitators on the interpersonal level (e.g., positive interactions with perinatal care providers and familial and social service supports) as positively shaping participants’ perinatal care experiences. Conclusions Findings reveal that the perinatal care experiences of people with IDD are shaped by several interrelated factors that largely stem from societal-level barriers, such as dominant (stigmatizing) discourses of disability. To improve the perinatal care experiences of people with IDD, there is a need for interventions at multiple levels. These include the development of policies to support perinatal care for diverse populations and training care providers to enact policies at the institutional and interpersonal levels.

Optimising preconception health-that is the health of women and men prior to a potential pregnancy-is increasingly recognised as fundamental to improving maternal and infant health outcomes. To date, limited research has been conducted examining preconception knowledge and studies focusing on preconception health behaviours have targeted certain behaviours, while overlooking others, with limited attention given to the interconception period and differences between multiparous and primiparous/nulliparous women.To determine predictors of preconception health knowledge among Canadian women and to examine whether parity modified the effect of predictors on preconception knowledge.A cross-sectional study reported according to STROBE was undertaken from May to June 2019 in Canada with 928 women. An online questionnaire was used including the Preconception Health Knowledge Questionnaire, demographic characteristics, current health status, previous pregnancy outcomes and use of preconception care services. Ordinary least squares regression was used to model knowledge scores. Predictors were entered using theoretically driven hierarchical entry.Mean age of women was 34 years and one in five were immigrants. In the final model, household income (b = .17, SE = .07; p = .009), being born outside Canada (b = -.75, SE = .25; p = .003), miscarriage/stillbirth history (b = .47, SE = .21; p = .027) and previous use of preconception care (b = .97, SE = .20, p ⟩ .001) were predictive of preconception health knowledge. Effect modification by parity was not statistically significant in the final model (f = 1.22, p = .19).Women at higher risk of poor preconception knowledge, and who therefore stand to gain from preconception knowledge interventions may include those who (1) are socially and economically disadvantaged; (2) have not engaged in preconception care previously and (3) were not born in Canada. Ensuring national promotion of and access to preconception care is an important strategy to prevent adverse pregnancy outcomes and optimise maternal and infant health.This study highlights the need for national promotion of and access to preconception health care for all pregnancy-planning families in order to improve perinatal outcomes.When evaluating preconception health efforts, preconception health knowledge must be considered within the context of social determinants of health and individuals' abilities to act on their knowledge.

Background Asthma is a risk factor for mental illness, but few studies have explored this association around the time of pregnancy. We studied the association between asthma and perinatal mental illness and explored the modifying effects of social and medical complexities. Methods In a population-based cohort of 846 155 women in Ontario, Canada, with a singleton live birth in 2005–2015 and no recent history of mental illness, modified Poisson regression models were constructed to examine the association between asthma diagnosed before pregnancy and perinatal mental illness, controlling for socio-demographics and medical history. We explored the modifying effects of social and medical complexities using relative excess risk due to interaction. Additional analyses examined the association between asthma and perinatal mental illness by timing and type of mental illness. Results Women with asthma were more likely than those without asthma to have perinatal mental illness [adjusted relative risk (aRR) 1.14; 95% (confidence interval) CI: 1.13, 1.16]. Asthma was associated with increased risk of diagnosis of mental illness prenatally (aRR 1.11; 95% CI: 1.08, 1.13) and post-partum (aRR 1.17; 95% CI: 1.15, 1.19) and specifically diagnoses of mood and anxiety disorders (aRR 1.14; 95% CI: 1.13, 1.16), psychotic disorders (aRR 1.20; 95% CI: 1.10, 1.31) and substance- or alcohol-use disorders (aRR 1.24; 95% CI: 1.14, 1.36). There was no effect modification related to social or medical complexity for these outcomes. Conclusions Women with asthma predating pregnancy are at slightly increased risk of mental illness in pregnancy and post-partum. A multidisciplinary management strategy may be required to ensure timely identification and treatment.

BACKGROUND: It is unclear whether the clinical burden of postpartum mental illness has increased during the COVID-19 pandemic. We sought to compare physician visit rates for postpartum mental illness in Ontario, Canada, during the pandemic with rates expected based on prepandemic patterns. METHODS: In this population-based, repeated cross-sectional study using linked health administrative databases in Ontario, Canada, we used negative binomial regression to model expected visit rates per 1000 postpartum people for March–November 2020 based on prepandemic data (January 2016–February 2020). We compared observed visit rates to expected visit rates for each month of the pandemic period, generating absolute rate differences, incidence rate ratios (IRRs) and their 95% confidence intervals (CIs). The primary outcome was a visit to a primary care physician or a psychiatrist for any mental disorder. We stratified analyses by maternal sociodemographic characteristics. RESULTS: In March 2020, the visit rate was 43.5/1000, with a rate difference of 3.11/1000 (95% CI 1.25–4.89) and an IRR of 1.08 (95% CI 1.03–1.13) compared with the expected rate. In April, the rate difference (10.9/1000, 95% CI 9.14–12.6) and IRR (1.30, 95% CI 1.24–1.36) were higher; this level was generally sustained through November 2020. From April–November, we observed elevated visit rates across provider types and for diagnoses of anxiety, depressive and alcohol or substance use disorders. Observed increases from expected visit rates were greater for people 0–90 days postpartum compared with 91–365 days postpartum; increases were small among people living in low-income neighbourhoods. Public health units in the northern areas of the province did not see sustained elevations in visit rates after July; southern health units had elevated rates through to November. INTERPRETATION: Increased visits for mental health conditions among postpartum people during the first 9 months of the COVID-19 pandemic suggest an increased need for effective and accessible mental health care for this population as the pandemic progresses.

While an increasing number of girls and women are being identified with autism, we know little about the health of reproductive-aged autistic women. Our objectives were to (1) describe health characteristics of reproductive-aged autistic women who could potentially become pregnant and (2) compare these characteristics with those of non-autistic women. We conducted a population-based cross-sectional study using 2017–2018 administrative health data from Ontario, Canada. A total of 6,870 fifteen- to 44-year-old autistic women were identified and compared with 2,686,160 non-autistic women. Variables of interest included social determinants of health (neighborhood income, residential instability, material deprivation, rurality), health (co-occurring medical and psychiatric conditions, use of potentially teratogenic medications, history of assault), and health care factors (continuity of primary care). Overall, reproductive-aged autistic women had poorer health compared with non-autistic women, including increased rates of material deprivation, chronic medical conditions, psychiatric conditions, use of potentially teratogenic medications, and history of assault. These findings highlight the need for health interventions tailored to the needs of reproductive-aged autistic women. Lay abstract While an increasing number of girls and women are being identified with autism, we know little about reproductive-aged autistic women’s health. This study used administrative data from Ontario, Canada, to compare the health of reproductive-aged autistic women with non-autistic women. Overall, reproductive-aged autistic women had poorer health compared with non-autistic women, including increased rates of material deprivation, chronic medical conditions, psychiatric conditions, history of assault, and use of potentially teratogenic medications (i.e. drugs that can be harmful to the development of an embryo or fetus). These findings suggest that there is a need for health interventions tailored to the needs of reproductive-aged autistic women.

Background: There is growing recognition that preconception health, defined as the health of all reproductive-age individuals, impacts reproductive and perinatal outcomes. Although women with disabilities are becoming pregnant at increasing rates, little is known about their preconception health. Our objective was to describe the preconception health characteristics of women with physical, sensory, and intellectual/developmental disabilities and compare these characteristics with women without disabilities. Materials and Methods: We conducted a population-based cross-sectional study of 15- to 44-year-old women with physical (n = 253,184), sensory (n = 93,170), intellectual/developmental (n = 8,986), and multiple disabilities (n = 29,868), and women without these disabilities (n = 2,307,822) using Ontario health administrative data (2017–2018). We described preconception health variables related to social determinants of health, physical health status, psychosocial well-being, history of assault, medication use, and continuity of primary care and compared women with and without disabilities in crude and age-standardized analyses, with standardized differences >0.10 indicating clinically meaningful results. Results: Women with physical, sensory, intellectual/developmental, and multiple disabilities had poorer preconception health than women without disabilities. Disparities were pronounced for physical health status, psychosocial well-being, use of potentially teratogenic medications, and history of assault. Of all groups, women with intellectual/developmental disabilities had the greatest disparities. Conclusion: Further research is needed to identify contributors to poor preconception health among women with disabilities and to develop tailored preconception health interventions to meet their unique needs and experiences.

Objectives: To examine the relationship between prepregnancy chronic medical conditions (CMCs) and the risk of acute perinatal psychiatric health-care encounters (i.e., psychiatric emergency department visits, hospitalizations) among refugees, nonrefugee immigrants, and long-term residents in Ontario. Methods: We conducted a population-based study of 15- to 49-year-old refugees ( N = 29,189), nonrefugee immigrants ( N = 187,430), and long-term residents ( N = 641,385) with and without CMC in Ontario, Canada, with a singleton live birth in 2005 to 2015 and no treatment for mental illness in the 2 years before pregnancy. Modified Poisson regression was used to estimate the relative risk of a psychiatric emergency department visit or hospitalization from conception until 1 year postpartum among women with versus without CMC, stratified by migrant status. An unstratified model with an interaction term between CMC and migrant status was used to test for multiplicativity of effects. Results: The association between CMC and risk of a psychiatric emergency department visit or hospitalization was stronger among refugees (adjusted relative risk [aRR] = 1.87; 95% confidence interval [CI], 1.36 to 2.58) compared to long-term residents (aRR = 1.39; 95% CI, 1.30 to 1.48; interaction P = 0.047). The strength of the association was no different in nonrefugee immigrants (aRR = 1.26; 95% CI, 1.05 to 1.51) compared to long-term residents (interaction P = 0.45). Conclusion: Our study identifies refugee women with CMC as a high-risk group for acute psychiatric health care in the perinatal period. Preventive psychosocial interventions may be warranted to enhance supportive resources for all women with CMC and, in particular refugee women, to reduce the risk of acute psychiatric health care in the perinatal period.

Preconception health impacts perinatal outcomes, but the difficulty in engaging reproductive-aged individuals in health promotion activities is a barrier to effective implementation of preconception interventions. Since most women have more than one pregnancy and many risk factors repeat across pregnancies, the time between pregnancies—the interconception period—may be an opportune time to improve health. Our objective was to examine the feasibility and acceptability of an interconception intervention delivered by public health nurses. We conducted a pilot randomized controlled trial in three small urban and rural public health units in Ontario, Canada, in 2017–2018 among women who were ≥ 18 years of age and between 2 and 12 months postpartum after a first birth. Women randomly allocated to the intervention group received a preconception risk assessment, tailored health education, and referral for clinical follow-up as needed, while those in the control group received standard care. Primary outcomes were intervention feasibility, adherence, and acceptability. Of 66 eligible women, 61% agreed to participate and were randomized to the intervention (n = 16) or control (n = 24) groups. The follow-up rate was 78% at 1 month and 71% at 3 months. Most women (83%) were satisfied with the intervention, including the number and length of sessions and content of recommendations. Results demonstrate the potential feasibility and acceptability of an interconception intervention delivered in a public health setting. The short- and long-term impacts of the intervention on knowledge, behavior, and health should be tested in a larger sample.

Out-of-home care in childhood and adolescence has been shown to be associated with elevated risk for all-cause mortality in adulthood, with adverse socioeconomic, psychosocial, and health-related trajectories hypothesized to mediate this relationship. In the research letter by Batty and Hamer (Am J Epidemiol. 2021;190(1):176–178), the authors used data from the 1970 British birth cohort (n = 8,581) to examine risk of biomarkers for mortality in adults with a history of out-of-home care. While markers of inflammation, glucose metabolism, and lipids were less favorable in the exposed versus unexposed, differences between groups were small and were completely attenuated after adjustment. This study raises important issues regarding the design and conceptualization of future studies on the long-term outcomes of out-of-home care recipients. Such studies require more detailed information on duration of care, type of care setting, and reasons for care, all of which could affect outcome risk. Because the duration of follow-up is long, and attrition likely, authors should consider use of novel analytical techniques to account for selection bias, such as inverse probability weighting. Finally, a “chain-of-risk” approach to understanding outcomes might be warranted, given that risk is likely explained by accumulation of and prolonged exposure to adverse socioeconomic, psychosocial, and health risks.