PRISM :: Browsing by Author "Metcalfe, Amy"

Browsing by Author "Metcalfe, Amy"

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Open Access
Age-period-cohort effects in pre-existing and pregnancy-associated diseases amongst primiparous women
(2020-04-19) Metcalfe, Amy; Ahmed, Sofia B; Nerenberg, Kara
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.
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An Intersectional Approach to Addressing Discrimination Among Pregnant Individuals in a Contemporary Population: A Cross-Sectional Study
(2024-09-25) Dharamsi, Shazia; Metcalfe, Amy; Ahmed, Sofia; Ruzycki, Shannon
Background: Pregnant individuals may be vulnerable to discrimination due to existing social stigma and cultural norms surrounding pregnancy and motherhood, which can be exacerbated due to gender, race, or other aspects of their identity; however, it is unclear how intersecting identities overlap and interact to shape peoples’ everyday experiences. The purpose of this study was to compare the prevalence and experiences of discrimination among pregnant individuals with diverse intersectional identities. Methods: This secondary analysis used baseline data from 1,605 participants enrolled in a longitudinal pregnancy cohort study, the P3 Cohort Study. Latent class analysis was applied to identify different subgroups within the population based on combinations of their social positions and identities (i.e., race, gender expression, emotional health, physical health, income, disability, chronic illness, and age). Perceived discrimination was assessed via the Everyday Discrimination Scale (EDS), and linear regression was performed to compare the frequency, chronicity, and overall number of discriminatory encounters between subgroups. Results: Utilizing latent class analysis, the following three subgroups emerged: (1) Mostly Privileged and Healthy; (2) Somewhat Privileged with Chronic Conditions; (3) Somewhat Privileged, Predominantly Racialized. Class 2 (βfrequency = 0.8, p = 0.042; βchronicity = 45.2, p < 0.001; βsituations = 0.4, p = 0.040) and Class 3 (βfrequency = 0.2, p < 0.001; βchronicity = 31.5, p < 0.001; βsituations = 0.5, p < 0.001) were both positively associated with the frequency, chronicity, and total number of discrimination situations relative to Class 1. The primary reported reasons underlying discrimination experiences varied across latent classes, reflecting the intersecting identities that defined each cluster.
Open Access
The association between temporal changes in the use of obstetrical intervention and small- for-gestational age live births
(BMC, 2015-09-29) Metcalfe, Amy; Lisonkova, Sarka; Joseph, KS
Background: The literature attributes secular declines in small-for-gestational age (SGA) live births to changes in maternal smoking and other maternal characteristics. However, there are reasons to believe that the observed reductions in SGA may be a consequence of early delivery following obstetric intervention. Methods: We examined temporal trends in obstetrical intervention and SGA among singleton live births in the United States from 1990 to 2010. The modified Kitagawa decomposition, based on the fetuses-at-risk approach, was used to assess the relative contribution of changes in the gestational age distribution and gestational age-specific SGA to overall changes in SGA. Reductions in SGA rates due to a left shift in the gestational age distribution were assumed to primarily reflect increased obstetrical intervention, whereas decreases in overall SGA due to decreases in gestational-age-specific SGA rates were assumed to reflect declines in risk factors. Results: Temporal trends in SGA followed a non-linear pattern, with substantial declines from 10.1 % in 1990–92 to 8.9 % in 2002–04, followed by a small increase to 9.1 % in 2008–10. Rates of maternal smoking steadily decreased throughout the same time period and changes in SGA rates were more consistent with changes in the gestational age distribution. The modified Kitagawa decomposition analysis also attributed the initial decline in SGA rates to changes in the gestational age distribution. Conclusions: Complex temporal pattern in SGA rates cannot be explained by the linear pattern of changes in factors like maternal smoking. Changes in the gestational age distribution are more consistent with the observed secular trends in SGA rates.
Open Access
Association of prenatal medical risk with breastfeeding outcomes up to 12 months in the All Our Families community-based birth cohort
(2021-09-15) Scime, Natalie V.; Metcalfe, Amy; Nettel-Aguirre, Alberto; Tough, Suzanne C.; Chaput, Kathleen H.
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.
Open Access
Breastfeeding difficulties in the first 6 weeks postpartum among mothers with chronic conditions: a latent class analysis
(2023-02-02) Scime, Natalie V.; Metcalfe, Amy; Nettel-Aguirre, Alberto; Nerenberg, Kara; Seow, Cynthia H.; Tough, Suzanne C.; Chaput, Kathleen H.
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.
Open Access
Breastfeeding intentions, difficulties, and outcomes in mothers with chronic physical health conditions: the Motherhood and Chronic Illness (MaCI) prospective cohort study
(2022-07-11) Scime, Natalie V.; Chaput, Kathleen H; Tough, Suzanne C; Metcalfe, Amy; Nettel-Aguirre, Alberto
Breastfeeding from birth to 6 months has numerous benefits for maternal and child health. Mothers with chronic conditions are at risk for suboptimal breastfeeding outcomes, yet the underlying reasons for this are poorly understood. This thesis research investigated the factors associated with breastfeeding intentions, difficulties, and outcomes in mothers with chronic conditions. We conducted a prospective, community-based pregnancy cohort study called the Motherhood and Chronic Illness (MaCI) Study following 405 women from Alberta who reported living with a long-term physical health condition, carrying a singleton pregnancy, and intending to try breastfeeding. Women completed questionnaires at 32 weeks gestation, 6 weeks postpartum, and 6 months postpartum (overall response rate, 86.7%). In the prenatal period, we found that women who perceived their chronic condition to worsen during pregnancy were less likely to plan to exclusively breastfeed to 6 months per the global recommendation (adjusted odds ratio [OR] 0.50, 95% CI 0.30–0.82). From birth to 6 weeks postpartum, we identified three clusters of breastfeeding difficulties corresponding to physiologically expected lactation changes (51.1% of women), low milk production (15.4%), and ineffective latch (33.5%). Mothers with endocrine (adjusted relative risk ratio [RRR] 2.41, 95% CI 1.13–5.13), cardiovascular (adjusted RRR 2.87, 95% CI 1.02–8.09), and gastrointestinal (adjusted RRR 2.57, 95% CI 1.13–5.82) conditions were more likely to belong to the low milk production cluster and mothers with gastrointestinal (adjusted RRR 2.47, 95% CI 1.27–4.81) conditions were more likely to belong to the ineffective latch cluster, relative to the physiologically expected cluster. By 6 months postpartum, we found that one third (31.2%) of mothers had stopped breastfeeding, nearly all of whom did so earlier than planned. Compared to mothers who adhered to their pre-existing medications, mothers who did not adhere to pre-existing medications had shorter breastfeeding duration (adjusted hazard ratio [HR] 1.69, 95% CI 1.04–2.74) and greater odds of earlier than planned breastfeeding cessation (adjusted OR 1.85, 1.01–3.41). The MaCI Study highlighted three unique determinants of breastfeeding in mothers with chronic conditions, which can be addressed through person-centred support that jointly considers the ways in which breastfeeding patterns influence, and are influenced by, chronic condition status and management.
Open Access
Cardiovascular Consequences of Hypertensive Disorders of Pregnancy
(2020-01) Wen, Chuan; Anderson, Todd J.; Nerenberg, Kara A.; Metcalfe, Amy; Johnson, Jo-Ann M.; Signal, Ronald J.; Tomfohr-Madsen, Lianne M.; McDonald, Sarah
Hypertensive disorders of pregnancy (HDP), including preeclampsia and gestational hypertension (GHTN), are independently associated with increased maternal cardiovascular risk. Endothelial dysfunction is one of the crucial pathophysiology of preeclampsia and might be the connection between preeclampsia and future cardiovascular risk. The postpartum period offers a time window to identify and begin to manage modifiable cardiovascular risk factors. However, limited studies have focused on the first years postpartum and the opportunity for early cardiovascular prevention may be lost. Few studies have longitudinally observed the changes of vascular function by different measures. The aims of this study were to detect: Subsequent hypertension, diabetes and dyslipidemia in women with/without HDP over the first years postpartum by linking three administrative databases. The alterations of vascular function during pregnancy by using flow-mediated vasodilation (FMD), hyperemic velocity-time integral (VTI) and peripheral artery tonometry (PAT), and the relationship between vascular function indices and utero-placental ultrasonographic and biochemical markers. Our results highlighted women with HDP had higher odds of hypertension (GHTN adjusted OR [aOR]: 5.82[4.96-6.83]; preeclampsia: aOR: 4.97[3.63-6.81]), dyslipidemia (GHTN: aOR: 2.22[1.47-3.35]; preeclampsia: aOR: 1.41[1.10-1.80]), and diabetes (GHTN: aOR: 2.26[1.50, 13.4]; PE: 2.02[0.91, 4.46]) during 4 years postpartum than the normotensive pregnancy. Half of the women with HDP had no lipid testing. They were not more likely to be tested than normotensive women after adjusting for confounders. Women with GHTN and preeclampsia had less favorable and more atherogenic lab results than the normal controls. Non-significant changes of FMD and hyperemic VTI over pregnancy were detected. The PAT index declined consistently during pregnancy and this may have been related to vasodilator changes of baseline pulse wave amplitude. The uterine artery pulsatility index (UtA-PI) was not correlated with the standard measures of endothelial function. There were mild correlations between UtA-PI and baseline flow, sFlT-1 and ln(sFlt-1/PlGF ratio) with baseline flow and baseline VTI in the first trimester. Our study implies the needs of early postpartum screening for hypertension, dyslipidemia and dysglycemia in women with HDP. FMD, hyperemic VTI and PAT index might not be directly used as markers to represent the macrovascular and microvascular function during pregnancy.
Open Access
Development and validation of the Cannabis Exposure in Pregnancy Tool (CEPT): a mixed methods study
(2024-04-16) Chaput, Kathleen H.; McMorris, Carly A.; Metcalfe, Amy; Ringham, Catherine; McNeil, Deborah; Konschuh, Shaelen; Sycuro, Laura J.; McDonald, Sheila W.
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.
Open Access
Effect of Remote Peer-Counsellor- delivered Behavioral Activation and Peer-support for Antenatal Depression on Gestational Age at Delivery: a single-blind, randomized control trial
(2023-03-30) Chaput, Kathleen H.; Freeman, Makayla; McMorris, Carly; Metcalfe, Amy; Cameron, Emily E.; Jung, James; Tough, Suzanne; Hicks, Laurel M.; Dimidjian, Sona; Tomfohr-Madsen, Lianne M.
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.
Open Access
Evaluation of the Effect of Hospital and Physician Factors on Likelihood of Revision After Mid-Urethral Sling Placement
(2020-01) Brennand, Erin Alexandra; Quan, Hude; Metcalfe, Amy; Peng, Mingkai; McCaughey, Deirdre
Objective: To estimate rates of revision surgery after insertion of mesh midurethral slings (MUS) and explore if healthcare attributes such as physician specialty, annual operative volume, or hospital type are risk factors for this outcome. Methods: This study used a population-based retrospective cohort of women who underwent MUS insertion over a 13-year interval (2004–2017) in Alberta, Canada. The main outcome was subsequent surgery for revision of MUS, defined by a composite of surgical procedures. Exposures included annual number of MUS procedures performed by the surgeon, facility type, surgeon specialty, patient age, and concomitant prolapse repair. Mixed-effects logistic regression utilizing linear spines was used to test the a priori hypothesis that annual surgical volume would be inversely related in a non-linear fashion to risk of revision. Results: In a cohort of 19,511 women, cumulative rates of revision surgery were 3.36% (95% CI 3.06–3.68) at 5 years and 4.57% (95% CI 4.00–5.21) at 10 years. The first year after MUS insertion was the most vulnerable window, with 0.39% (95% CI 0.31–0.49) undergoing revision within 30 days and 2.05% (95% CI 1.85–2.26) within a year. Concomitant prolapse repairs (OR = 1.24, 95% CI 1.04–1.48) and surgeon’s annual volume were associated with revision. After 50 cases per year, odds of revision declined with each additional case (OR = 0.991 per case, 95% CI 0.983–0.999; OR = 0.91 per 10 cases, 95% CI 0.84–0.98) and plateaued at 110 cases per year. Surgeon specialty, hospital type, and patient age were not associated with outcome. Conclusions and relevance: Within 10 years, nearly 1 in 20 women underwent revision surgery after MUS insertion. Physician annual surgical volume appears to be a risk factor, with a decline in risk of revision surgery occurring at an annual threshold of >50 cases. Given that annual case volume is a potentially modifiable risk factor, development of policies regarding minimum caseload parameters for surgeons performing MUS procedures may hold potential to improve the quality of MUS surgery.
Open Access
Examining Neighbourhood Socioeconomic Status, Anxiety and Depression during Pregnancy, and Preterm Birth
(2019-07-10) Adhikari Dahal, Kamala; Metcalfe, Amy; Patten, Scott B.; Williamson, Tyler S.; Patel, Alka B.
Background: Understanding of influence of anxiety, depression, and neighbourhood socioeconomic status (SES) on the risk of preterm birth (PTB) is unclear. This doctoral research examined the ability of neighbourhood SES to predict the risk of PTB, the utility of existing anxiety scales in measuring anxiety in pregnancy, and whether neighbourhood SES modified the association between anxiety and depression during pregnancy and PTB. Methods: This study used data from two pregnancy cohort studies in Alberta, Canada (n=5,528). The data were linked to neighbourhood SES data, derived from the Canadian census. A multilevel logistic regression prediction model was developed to examine whether neighbourhood SES improves the prediction of PTB. Confirmatory factor analysis and Spearman correlation were used to examine the utility of anxiety scales in pregnancy. A multivariable logistic regression model was used to assess whether neighbourhood SES modifies the association between anxiety and/or depression and PTB. Results: Neighbourhood level variance explained PTB by 6%. Neighbourhood SES combined with maternal characteristics predicted PTB with an area under the receiver operating characteristic curve (AUC) of 0.75. Maternal characteristics alone had AUC of 0.60. The model fit of anxiety scales ranged from inadequate to adequate. The correlation between the scales was low to moderate. The presence of both anxiety and depression, but neither anxiety nor depression alone, was significantly associated with PTB (OR=1.57, 95% CI=1.07, 2.29) and had significant interaction with neighbourhood deprivation (p-value=0.014). Conclusions: This research may suggest that women’s neighbourhood SES improves overall prediction of PTB and that it modifies the effects of anxiety and depression on risk of PTB. It may also indicate that existing anxiety scales do not measure anxiety as a single dimension and they are incomparable. These findings may guide the identification of women at increased risk for PTB and future research in the field.
Open Access
Exclusive Breastfeeding and Assisted Reproductive Technologies: A Calgary Cohort
(OMICS Group Corporation, 2012-04-25) O'Quinn, Candace; Metcalfe, Amy; McDonald, Sheila W.; Raguz, Nikolett; Tough, Suzanne C.
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Feasibility of Postpartum Community Research: Results of a Systematic Review and A Pilot Randomized Controlled Trial to Optimize Postpartum Health Through Self-Scar Massage
(2024-05-29) Cerantola, Gina-Marie; Brennand, Erin; Metcalfe, Amy; Kania-Richmond, Ania; Bennion, Laura
Background The postpartum population is under-represented and under-funded in research. Postpartum pelvic health dysfunction is common, yet few evidence-informed pelvic health treatment options exist. Objectives 1. Assess feasibility of a randomized controlled trial (RCT) investigating self-massage of postpartum pelvic floor scar tissue on pelvic health outcomes. 2. Perform a systematic review to determine recruitment rate and retention in RCTs studying the postpartum population and recruitment strategies used in successful trials. Methods A pilot RCT was conducted to examine feasibility for a larger trial. Eligible and consenting primiparous postpartum adults with healed perineal tear(s) and/or episiotomy in Calgary, Alberta, were recruited for participation between 42 and 365 days postpartum. Participants were randomized into two groups with a 1:1 allocation. The intervention group performed self-scar massage of their pelvic floor scar tissue and the control group received routine postnatal care. Patient medical records were used to collect demographic and obstetrical data. All participants were asked to complete two reliable and validated pelvic health questionnaires upon enrollment in the study and then again 6 weeks later. The primary analysis determined the monthly recruitment rate, acceptability of intervention and questionnaires, and participant adherence to the intervention protocol. For the systematic review, eligible studies were selected through an electronic literature search. Databases were searched for original RCTs investigating interventions between 42 and 365 days postpartum that recruited participants postpartum. Results For the pilot RCT, the recruitment rate was one participant/month (n=6), and participant retention was 100%. Participants deemed the intervention and outcome measures acceptable, but reported challenges adhering to the intervention protocol, at times, due to competing demands of newborn care. For the systematic review, 39 studies were included from 18,580 records initially identified. The median recruitment rate was 6.58 participants/recruitment site/month (Interquartile Range (IQR):2.92-9.21) and the median percentage of retained participants was 90% (IQR:80-96). Conclusions Due to low recruitment rates for the pilot RCT, a future trial was deemed infeasible if the existing indirect recruitment strategy was used. Findings from the systematic review suggest that a future targeted recruitment approach may be preferred based on strategies used in postpartum RCTs with successful recruitment.
Open Access
Hospital and Individual Variations of Surgical Errors and Complications in Caesarean Section in the United States
(2018-06-04) Sheikh, Manal Salim; Metcalfe, Amy; Nelson, Gregg; Wood, Stephen L.
Background: Caesarean Section (CS) is the most common inpatient surgery performed internationally. Although CS is typically performed to prevent adverse maternal and fetal outcomes, there is still a risk of surgical errors and complications. This study examined maternal and hospital risk factors associated with errors and complications following CS in the United States (US). Methods: Data were obtained from the 2012-2014 National Inpatient Sample, a deidentified database containing a random sample of 20% of hospital discharges in the US. Surgical errors (e.g. foreign body retained during surgery) can be the result of human error, while complications (e.g. infection) can be due to external factors such as preexisting comorbidities. The overall incidence of surgical errors and complications in CS was calculated. Bivariate analysis examined the association between surgical errors and complications in CS, and potential individual and hospital level covariates. Multilevel logistic modelling examined the association between individual (e.g. race) and hospital (e.g. CS volume), and errors and complications. Results: Among 648,584 CS hospitalizations, 1.98% (95%CI: 1.95%-2.01%) and 9.67% (95%CI: 9.59%-9.74%) of women had an error or complication, respectively. The odds of developing a complication were 15.90 (95%CI: 15.33-16.49) if an error also occurred. Both individual- and hospital-level factors were associated with errors and complications. Women with Medicaid had increased odds of errors (OR: 1.40 (95%CI:1.37-1.43)) but lower odds of complications (OR: 0.89 (95%CI:0.88-0.90)), compared to women with private insurance. Compared to non-Hispanic white women, iii all races had lower odds of error, and only non-Hispanic black women had greater odds of complications (OR: 1.14 (95%CI:1.13-1.16)). Delivering prior to 37 weeks of gestation decreased the odds of errors (OR: 0.73 (95%CI:0.71-0.76)) and maternal complications (OR: 0.73 (95%CI:0.72-0.74)). Similarly, rural hospitals had lower odds of surgical errors (OR: 0.59 (95%CI: 0.56-0.62)) and complications (OR: 0.61 (95%CI: 0.59-0.62)) while hospitals with a large bed size had greater odds of errors and complications than medium bed size hospitals, at 1.13 (95%CI:1.09-1.17), and 1.13 (95%CI:1.11-1.15), respectively. Conclusions: This study identified specific risk factors for errors and complications that can be further examined through quality improvement frameworks to reduce the incidence of adverse maternal events during CS.
Open Access
Impact of Educational Intervention at the Inflammatory Bowel Disease Preconception and Pregnancy Clinic on Adherence to Cervical Cancer Screening
(2022-01-07) Ehteshami Afshar, Elnaz; Seow, Cynthia H; Kaplan, Gilaad G; Metcalfe, Amy
Adherence to cervical cancer screening (CCS) is critical for decreasing cervical cancer incidence and related mortality. Repeating Pap tests every three years in women with a population-based risk of cervical cancer and annually in high-risk patients, as a risk-appropriate approach, is highly recommended. Women with Inflammatory Bowel Disease (IBD) and exposed to immunosuppressive medications are considered high-risk patients. Promoting adherence to CCS by educational intervention has been studied previously; however, the extent of the impact among IBD patients is still unclear. Our study aims to assess the association between receiving health education, by physicians in the IBD pregnancy clinic, and adherence to CCS. A total of 190 individuals with IBD who visited the IBD pregnancy clinic between 2012 and 2016 were recruited. A one-group pretest-posttest study design was conducted. Data of Pap testing between 2007 and 2020 were collected and compared before (baseline) and after educational intervention by McNemar’s Test. Prior to the intervention, 29.47% (95% CI, 23.37 – 36.4) of participants had adherence to risk-appropriate CCS for two screening cycles before the health education. Importantly, participation in risk-appropriate screening immediately after receiving the health education increased significantly to 47.36% (proportion difference= 0.18, 95% CI, 0.08 – 0.27) (p<0.001). Long-term adherence to the population-based CCS was observed in 38.42% (95% CI, 31.72 – 45.6) of participants before the intervention and 34.74% (95% CI, 28.25 – 41.84) after the intervention. McNemar’s test result indicated no significant change in adherence to CCS for more than one cycle after the intervention (p=0.45). This study demonstrated that the participation rate in CCS among IBD patients, particularly those on immunosuppressive therapy, was less than the target rate determined by the provincial health care system. The participation rate in the first risk-appropriate CCS improved significantly after receiving the educational intervention. However, the longevity of behaviour change was not determined. The finding may be due to the small sample size and diverse Pap testing intervals recommendations in different versions of guidelines. Further investigations are required to address the exact reasons for these findings and design an intervention that translates into prolonged behaviour changes.
Open Access
Impact of prenatal care provider on the use of ancillary health services during pregnancy
(BioMed Central, 2013-03-11) Metcalfe, Amy; Grabowska, Kristen; Weller, Carol; Tough, Suzanne C
Open Access
Integrative health care – What are the relevant health outcomes from a practice perspective? A survey
(2017-12-22) Kania-Richmond, Ania; Metcalfe, Amy
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.
Embargo
Investigating the association between prenatal provider specialty and postpartum glucose testing in people with gestational diabetes: a retrospective analysis of a population-based Canadian cohort.
(2024-07-03) Charlong, Kathleen Mackenzie; Metcalfe, Amy; Rabi, Doreen; Cuthbert, Colleen
Background Gestational diabetes mellitus (GDM) increases future risk of type 2 diabetes and cardiovascular disease. Diabetes Canada guidelines recommend postpartum glucose tolerance testing for everyone with GDM, yet uptake is low. Most evidence of barriers to testing comes from international sources and may not be generalizable to the Canadian perinatal context. Canadian maternity care providers include general practitioners (GPs), obstetricians (OBs), and registered midwives (RMs), with care models that differ from each other and from international providers of the same titles. There is a need for Canadian population-based studies exploring systems-level factors associated with low postpartum screening uptake. Methods We used de-identified population-based data on all births in Alberta, Canada between 2017 and 2018. We identified prenatal care provider specialty, glucose testing incidence, and cohort demographics. The study outcomes were 1) reciept of the gold standard protocol: oral glucose tolerance test (OGTT) within 6 weeks to 6 months, and 2) any glucose test occurring within 6 weeks to 1 year postpartum. We used logistic regression, adjusted for clinically relevant covariates, to estimate an association between test uptake and provider specialty. Results From 105,691 births we identified a GDM cohort of 9,884 eligible births. Cohort proportions of each prenatal care provider were OB (58.6%), GP (38.5%), and RM (2.9%). Overall test incidence was low; 22.2% (95% CI: 21.4 – 23.1) received gold standard testing and 53.9% (95% CI: 52.9 – 54.9) received any testing. When compared to the OB group, people in the GP group were less likely to receive follow-up testing (ORGS= 0.86, 95% CI: 0.77 – 0.95; ORAny= 0.88, 95% CI: 0.81 – 0.96). Those with RM care were also less likely to receive follow-up testing (ORGS= 0.67, 95% CI: 0.46 – 0.96; ORAny= 0.88, 95% CI: 0.67 – 1.15) when compared to the OB group. Discussion The overall proportion of people receiving postpartum glucose testing was low, indicating that efforts to improve screening uptake should be targeted to all care providers.
Open Access
Laboratory Use in Individuals with Early-Onset versus Usual-Onset of Diabetes: A Retrospective Cohort Study
(2023-07) Sriskandarajah, Apishanthi; Butalia, Sonia; Metcalfe, Amy; Nerenberg, Kara
Background: The incidence and prevalence of diabetes is increasing in younger individuals and these individuals are at an increased risk of complications. Laboratory testing is used to screen and monitor for complications in people with diabetes, and there is concern that this is not being achieved as per clinical guidelines. The objective of this thesis was to describe the frequency and results of guideline recommended laboratory tests in individuals with early-onset (<40 years of age) and usual-onset diabetes (≥40 years of age), and to explore clinical and sociodemographic factors related to guideline concordance of frequency of testing and results. Methods: This observational, retrospective cohort study used population-based administrative and clinical databases in Alberta from 2018 to 2019. We included adults with incident diabetes (age ≥18 years) and stratified by age of onset (<40 years versus ≥40 years). Individuals were followed for a total of 365 days for glycated hemoglobin (A1C), low-density lipoprotein cholesterol (LDL-C), estimated glomerular filtration rate (eGFR), and albumin to creatinine ratio (ACR) tests. Descriptive statistics were used to compare laboratory testing between early-onset and usual-onset groups. Multivariable logistic regression was used to assess factors related to guideline concordant testing frequency and above-target results. Results: Overall, the cohort included 23,643 individuals with incident diabetes (mean age 54.1 ± SD 15.4 years, 42.1% female). The early-onset group represented 18.9% of the cohort. A higher proportion of the early-onset group had lower frequency of testing for A1C, LDL-C, eGFR, and ACR tests and above-target test results for A1C and LDL-C compared to the usual-onset group. After adjustment of covariates (sex, socioeconomic status, rural residence, medication use), the early-onset group was more likely to have lower frequency of testing for A1C, LDL-C, and eGFR tests and above-target A1C and LDL-C levels compared to the usual-onset group. Sociodemographic and clinical factors were also associated with testing frequency and above-target test results. Conclusions: Despite a universal health care system, the early-onset group was not meeting clinical guidelines for testing frequency or targets. Future work is needed to inform tools and strategies to improve guideline recommended laboratory use in this group.
Open Access
Mental health outcomes of mothers who conceived using fertility treatment
(BioMed Central, 2014-02-28) Raguz, Nikolett; McDonald, Sheila; Metcalfe, Amy; O'Quinn, Candace; Tough, Suzanne C