The Effect of Maternal Age on Adverse Birth Outcomes: Does Parity Matter?

ObjectivesTo examine the effect of parity on the association between older maternal age and adverse birth outcomes, specifically stillbirth, neonatal death, preterm birth, small for gestational age, and neonatal intensive care unit admission.MethodsWe conducted a retrospective cohort study of singleton births in British Columbia between 1999 and 2004. In the cohort, 69 023 women were aged 20 to 29, 25 058 were aged 35 to 39, and 4816 were aged 40 and over. Perinatal risk factors, obstetric history, and birth outcomes were abstracted from the British Columbia Perinatal Database Registry. Logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals for adverse outcomes in the two older age groups compared with the young control subjects.ResultsCompared with younger control subjects, women aged 35 to 39 years had an aOR of stillbirth of 1.5 (95% CI 1.2 to 1.9) and women aged ≥ 40 years also had an aOR of 1.5 (95% CI 1.0 to 2.4). The aOR for NICU admission was 1.2 (95% CI 1.0 to 1.3) in women aged 35 to 39 years and 1.4 (95% CI 1.1 to 17) in women aged ≥ 40 years compared with younger control subjects. The risk of preterm birth and SGA differed by parity. The aOR for preterm birth compared with younger primiparas was 1.5 (95% CI 1.4 to 1.7) for women aged 35 to 39 years and 1.6 (95% CI 1.3 to 2.0) for women aged ≥ 40 years. In multiparas the aOR for preterm birth was 1.1 (95% CI 1.1 to 1.2) in women aged 35 to 39 and 1.3 (95% CI 1.1 to 1.5) in women > 40 years. The aOR for SGA in primiparas was 1.2 (95% CI 1.1 to 1.4) for women aged 35 to 39 and 1.4 (95% CI 1.1 to 1.7) for women aged ≥ 40 years. The risk of neonatal death was not significantly different between groups.ConclusionOlder women were at elevated risk of stillbirth, preterm birth, and NICU admission regardless of parity. Parity modified the effect of maternal age on preterm birth and SGA. Older primiparas were at elevated risk for SGA, but no association between age and SGA was found in multiparas. Older primiparas were at higher risk of preterm birth than older multiparas compared with younger women.     

Travel Time to Delivery,Antenatal Care,and Birth Outcomes: A Population-Based Cohort of Uncomplicated Pregnancies in British Columbia, 2012–2019

ObjectiveHealth policy and system leaders need to know whether long travel time to a delivery facility adversely affects birth outcomes. In this study, we estimated associations between travel time to delivery and outcomes in low-risk pregnancies.MethodsThis population-based cohort included all singleton births without obstetric comorbidities or intrapartum facility transfers in British Columbia, Canada, from 2012 to 2019. Travel time was measured from maternal residential postal code to delivery facility using road network analysis. We estimated associations between travel time and severe maternal morbidity, stillbirth, pre-term birth, and small-for-gestational age (SGA) and large-for-gestational age (LGA) status using logistic regression, adjusted for confounders (adjusted odds ratios [aORs]). To examine variations in associations between travel time and outcomes by antenatal care utilization, we stratified models by antenatal care categories.ResultsOf 232 698 births, 3.8% occurred at a facility ≥60 minutes from the maternal residence. Obesity, adolescent age, substance use, inadequate prenatal care, and low socioeconomic status were more frequent among those traveling farther for delivery. Travel time ≥120 minutes was associated with increased risk of stillbirth (aOR 1.8; 95% CI 1.2–2.8), pre-term birth (aOR 2.3; 95% CI 2.1–2.5), LGA (aOR 1.5; 95% CI 1.4–1.6), and severe maternal morbidity (aOR 1.5; 95% CI 1.2–1.8), but not SGA (aOR 1.0; 95% CI 0.8–1.1), when compared with a travel time of 1–29 minutes. Risk of stillbirth was greatest with inadequate and intensive (adequate plus) antenatal care but persisted for severe maternal morbidity, pre-term birth, and LGA across categories.ConclusionLonger travel time to delivery was associated with increased risk of adverse outcomes in low-risk pregnancies after adjusting for confounding factors. Associations were stronger among those with inadequate antenatal care.     

Cannabis Use During the Pre-Conception Period and Pregnancy After Legalization

ObjectiveThere is limited evidence of the impact of cannabis legalization on the prevalence of cannabis use and use of other substances. The aim of this exploratory observational study was to compare rates of cannabis use, cigarette smoking, alcohol consumption, and the use of any street drugs during the preconception period and in pregnancy in two convenience samples of pregnant persons in British Columbia, Canada, before and after the legalization of cannabis.MethodsAny pregnant person residing in British Columbia, aged >19 years, at any gestational age was eligible to participate. Pre- and post-legalization study participants were recruited between May and October 2018 and July 2019 and May 2020, respectively. Multivariate models were constructed to examine the effect of legalization on cigarette smoking and the use of cannabis, alcohol, and street drugs, adjusting for demographic, pre-pregnancy, and pregnancy confounders.ResultsFrom pre- to post-legalization, the prevalence of self-reported cannabis use during the preconception period increased significantly, from 11.74% (95% CI 9.19%–14.88%) to 19.38% (95% CI 15.45%–24.03%). Rates of cannabis use during pregnancy also increased from 3.64% (95% CI 2.32%–5.69%) before legalization to 4.62% (95% CI 2.82%–7.47%) after; however, this difference was not statistically significant. Adjusting for potential confounders, the post-legalization group had significantly higher odds of cannabis use during the preconception period (adjusted odds ratio 1.71; 95% CI 1.14–2.58) but not during pregnancy (adjusted odds ratio 1.66; 95% CI 0.75–3.65). Legalization was also not associated with significant changes in cigarette smoking, alcohol consumption, or the use of street drugs during the preconception period and pregnancy, after adjusting for potential confounders.ConclusionThe preliminary evidence presented in this study shows that the legalization of cannabis was associated with 71% higher odds of cannabis use during the preconception period. Studies examining the effects of cannabis use on perinatal outcomes, as well as public health interventions and educational programs related to cannabis use, should include the preconception period as an area of focus.     

Is small for gestational age a marker of future fetal survival in utero?

OBJECTIVE: We sought to assess whether small for gestational age is a risk factor for stillbirth of a subsequent sibling. METHODS: The Missouri maternally linked cohort data set, containing data on births from 1978 through 1997, was used. We identified the study group (women who delivered a SGA infant in the first pregnancy) and a comparison group (women who delivered a non-SGA infant in their first pregnancy) and compared the outcome (stillbirth) in the second pregnancy between both groups. RESULTS: We analyzed information on the first and second pregnancies of 402,015 women (43,549 [10.8%] in the study arm and 358,466 [89.2%] in the comparison arm). Of the 1,883 cases of stillbirth in the second pregnancy, 314 cases occurred in mothers with a history of SGA (stillbirth rate 7.2/1,000) and 1,569 in the comparison group (stillbirth rate 4.4/1,000), P < .001. The adjusted risk of stillbirth was 60% higher in women with a prior SGA (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.4-1.8). The risk for stillbirth in the second pregnancy increased with decreasing gestational age at birth of the SGA infant in the first pregnancy (term: OR 1.4, 95% CI 1.2-1.6; preterm: OR 2.8, 95% CI 2.0-3.8; and very preterm: OR 4.2, 95% CI 2.4-7.3), P for trend < .001. CONCLUSION: Small for gestational age is a marker for subsequent stillbirth, and the risk rises with decreasing gestational age of the SGA birth. This information is potentially useful for counseling parents of SGA infants. LEVEL OF EVIDENCE: II-2.     

Neighbourhood Family Income and Adverse Birth Outcomes Among Singleton Deliveries

ObjectiveTo assess the association between neighbourhood family income and adverse birth outcomes.MethodsWe conducted a retrospective cohort study of 334 231 singleton births during 2004 and 2006 based on the Niday Perinatal Database from Ontario. Median neighbourhood family incomes from the 2001 Canadian census were linked with the Niday Perinatal Database by dissemination areas. Generalized estimating equations were applied to estimate the odds ratios of adverse birth outcomes associated with lower neighbourhood income, with adjustment for maternal confounding variables at the individual level.ResultsCompared with the highest neighbourhood income quintile, mothers from the lowest quintile were at increased risk of having small for gestational age neonates (OR 1.51; 95% CI 1.46 to 1.57), low birth weight (OR 1.43; 95% CI 1.36 to 1.50), preterm birth (OR 1.17; 95% CI 1.12 to 1.23), low Apgar score (< 7) at five minutes (OR 1.32; 95% CI 1.21 to 1.44), and stillbirth (OR 1.39; 95% CI 1.19 to 1.62). The risks of women from the lowest income quintiles delivering a macrosomic baby (OR 0.81; 95% CI 0.79 to 0.84) or a large for gestational age baby (OR 0.82; 95% CI 0.80 to 0.85) were significantly decreased. No difference in risk of congenital anomaly was found among different income quintiles.ConclusionA lower level of neighbourhood income is associated with increased risks of small for gestational age babies, low birth weight, preterm birth, low Apgar score at five minutes, and stillbirth.     

A Population-Based Study of Antenatal Corticosteroid Prophylaxis for Preterm Birth

ObjectiveNational and international clinical practice guidelines,based on the meta-analysis of randomized trials, recommend antenatal corticosteroid (ACS) prophylaxis for threatened preterm delivery. We carried out a study to determine the extent to which current clinical practice in British Columbia adheres to these guidelines with a focus on preterm deliveries at 33 to 34 weeks of gestation.MethodsData were obtained from the British Columbia Perinatal Database Registry, a comprehensive provincial registry containing detailed information on all births in the province. All preterm live births between 2000 and 2009 were included in the study. The rate of ACS administration was assessed in different gestational age groups. Determinants of ACS administration (such as maternal characteristics and obstetric factors) were also studied. The frequency of ACS prophylaxis was estimated using rates and exact 95% confidence intervals, and associations were assessed using odds ratios and 95% confidence intervals.ResultsAmong 35 862 preterm births in British Columbia, the rate of ACS administration was 56.0% in the 26- to 32-week group (95% CI 54.7% to 57.4%) and 19.4% in the 33- to 34- week group (95% CI 18.5% to 20.4%). Rates were reasonably consistent between 2000 and 2009 and by region of residence in British Columbia. Women with hypertension (OR 1.51; 95% CI 1.32 to 1.72), gestational diabetes (OR 1.21; 95% CI 1.05 t01.40), and iatrogenic deliveries (OR 1.34; 95% CI 1.22 to 1.47) were significantly more likely to receive ACS.ConclusionDespite explicit clinical guidelines, ACS usage in preterm deliveries at 33 to 34 weeks of gestation appears to be suboptimal.     

Prevalence and risk factors related to preterm birth in Brazil

Background

The rate of preterm birth has been increasing worldwide, including in Brazil. This constitutes a significant public health challenge because of the higher levels of morbidity and mortality and long-term health effects associated with preterm birth. This study describes and quantifies factors affecting spontaneous and provider-initiated preterm birth in Brazil.

Methods

Data are from the 2011–2012 “Birth in Brazil” study, which used a national population-based sample of 23,940 women. We analyzed the variables following a three-level hierarchical methodology. For each level, we performed non-conditional multiple logistic regression for both spontaneous and provider-initiated preterm birth.

Results

The rate of preterm birth was 11.5 %?, (95 % confidence 10.3 % to 12.9 %) 60.7 % spontaneous - with spontaneous onset of labor or premature preterm rupture of membranes - and 39.3 % provider-initiated, with more than 90 % of the last group being pre-labor cesarean deliveries. Socio-demographic factors associated with spontaneous preterm birth were adolescent pregnancy, low total years of schooling, and inadequate prenatal care. Other risk factors were previous preterm birth (OR 3.74; 95 % CI 2.92–4.79), multiple pregnancy (OR 16.42; 95 % CI 10.56–25.53), abruptio placentae (OR 2.38; 95 % CI 1.27–4.47) and infections (OR 4.89; 95 % CI 1.72–13.88). In contrast, provider-initiated preterm birth was associated with private childbirth healthcare (OR 1.47; 95 % CI 1.09–1.97), advanced-age pregnancy (OR 1.27; 95 % CI 1.01–1.59), two or more prior cesarean deliveries (OR 1.64; 95 % CI 1.19–2.26), multiple pregnancy (OR 20.29; 95 % CI 12.58–32.72) and any maternal or fetal pathology (OR 6.84; 95 % CI 5.56–8.42).

Conclusion

The high proportion of provider-initiated preterm birth and its association with prior cesarean deliveries and all of the studied maternal/fetal pathologies suggest that a reduction of this type of prematurity may be possible. The association of spontaneous preterm birth with socially-disadvantaged groups reaffirms that the reduction of social and health inequalities should continue to be a national priority.

     

Maternal Area of Residence,Socioeconomic Status,and Risk of Adverse Maternal and Birth Outcomes in Adolescent Mothers

ObjectiveAdolescent pregnancy is a significant public health issue in Canada. Current evidence highlights the individual role of social determinants of health such as maternal residence and socioeconomic status (SES) on teen pregnancy outcomes. This study evaluated the joint association between residence/SES and adverse adolescent pregnancy outcomes.MethodsThis was a population-based retrospective cohort study of all singleton, live deliveries (2010-2015) from women aged 15 to 19 who were registered in the Alberta Perinatal Health Program. Information on maternal residence and SES was extracted from the Pampalon Material Deprivation Index data set. The study categorized mothers into four risk dyads: rural/high SES, rural/low SES, urban/high SES, and urban/low SES. Adjusted odds ratios (ORs) of adverse pregnancy outcomes were calculated in logistic regression models (Canadian Task Force Classification II-2).ResultsA total of 9606 births from adolescent mothers were evaluated. Thirty percent of adolescent mothers were classified as urban/high SES; 27% were urban/low SES; 7% were rural/high SES; and 36% were placed in the rural/low SES category. Compared with urban/high SES mothers, rural/low SES mothers had increased odds of postpartum hemorrhage (OR 1.57; 95% confidence interval [CI] 1.41–1.74), operative vaginal delivery (OR 1.37; 95% CI 1.18–1.60), Caesarean section (OR 1.39; 95% CI 1.19–1.62), large for gestational age infants (OR 1.39; 95% CI 1.16–1.66), low birth weight (OR 1.11; 95% CI 1.07–1.65), and preterm birth (OR 1.48; 95% CI 1.17–1.87).ConclusionRural pregnant adolescents of low SES have the highest odds for adverse pregnancy outcomes. Social determinants of health that affect adolescent pregnancies need further examination to identify high-risk subgroups and understand pathways to health disparities in this vulnerable population.     

Precancerous changes in the cervix and risk of subsequent preterm birth

OBJECTIVE: The aims of this study were (i) to examine whether women referred for assessment of precancerous changes in the cervix had higher rates of preterm birth compared with those in the general population and (ii) to compare preterm birth rates for treated and untreated women adjusting for possible confounding factors. DESIGN: Retrospective cohort design. SETTING: Teaching hospital. POPULATION: All women referred to the Royal Women's Hospital, Melbourne (1982-2000), who subsequently had a birth recorded on the Victorian Perinatal Data Collection system (n = 5548). METHODS: Record linkage of hospital dysplasia clinic records and population-based birth records. MAIN OUTCOME MEASURES: Total preterm delivery (<37 weeks of gestation) and subtypes. RESULTS: Both treated and untreated women were at a significantly increased risk for preterm birth compared with those in the general population: treated--standardised prevalence ratio (SPR) 2.0, 95% CI 1.8-2.3 and untreated--SPR 1.5, 95% CI 1.4-1.7. Within the cohort, the treated women were significantly more likely to give birth preterm (adjusted OR 1.23, 95% CI 1.01-1.51). An increased risk of preterm birth was also associated with a history of induced or spontaneous abortions, illicit drug use during pregnancy or a major maternal medical condition. Cone biopsy, loop electrosurgical excision procedure and diathermy were associated with preterm birth. After adjusting for possible confounding factors, only diathermy remained significant (adjusted OR 1.72, 95% CI 1.36-2.17). Women treated using laser ablation were not at an increased risk for preterm birth (adjusted OR 1.1, 95% CI 0.8-1.4). CONCLUSIONS: Diagnosis of precancerous changes in the cervix (regardless of the treatment) was associated with an increased risk of preterm birth. Consideration should be given to the preferential use of ablative treatments.     

The Association of Inadequate and Intensive Prenatal Care With Maternal,Fetal, and Infant Outcomes: A Population-Based Study in Manitoba,Canada

ObjectiveLittle is known about how prenatal care influences health outcomes in Canada. The objective of this study was to examine the association of prenatal care utilization with maternal, fetal, and infant outcomes in Manitoba.MethodsThis retrospective cohort study conducted at the Manitoba Centre for Health Policy investigated all deliveries of singleton births from 2004-2005 to 2008-2009 (N = 67 076). The proportion of women receiving inadequate, intermediate/adequate, and intensive prenatal care was calculated. Multivariable logistic regression was used to examine the association of inadequate and intensive prenatal care with maternal and fetal-infant health outcomes, health care use, and maternal health-related behaviours.ResultsThe distribution of prenatal care utilization was 11.6% inadequate, 84.4% intermediate/adequate, and 4.0% intensive. After adjusting for sociodemographic factors and maternal health conditions, inadequate prenatal care was associated with increased odds of stillbirth, preterm birth, low birth weight, small for gestational age (SGA), admission to the NICU, postpartum depressive/anxiety disorders, and short interpregnancy interval to next birth. Women with inadequate prenatal care had reduced odds of initiating breastfeeding or having their infant immunized. Intensive prenatal care was associated with reduced odds of stillbirth, preterm birth, and low birth weight and increased odds of postpartum depressive/anxiety disorders, initiation of breastfeeding, and infant immunization.ConclusionInadequate prenatal care was associated with increased odds of several adverse pregnancy outcomes and lower likelihood of health-related behaviours, whereas intensive prenatal care was associated with reduced odds of some adverse pregnancy outcomes and higher likelihood of health-related behaviours. Ensuring women receive adequate prenatal care may improve pregnancy outcomes.     

Short interpregnancy interval and risk of spontaneous preterm delivery

OBJECTIVES: Short interpregnancy intervals are related to increased prevalence of adverse perinatal outcomes. However, the reported association with preterm birth might be due to confounding by factors such as previous pregnancy outcomes, socioeconomic level or lifestyles. The objective of this study was to evaluate the effect of short interpregnancy interval on the occurrence of spontaneous preterm delivery. STUDY DESIGN: The prevalence of a short interpregnancy interval, defined as six or less months between a preceding delivery or abortion and the last menstrual period before index pregnancy, was compared between 263 spontaneous preterm (<37 weeks) and 299 term (37-42 weeks) consecutive births. Separate analyses were performed for early (<34 weeks) and late (34-36 weeks) preterm deliveries. Crude and adjusted odds ratios (ORs) and 95% confidence intervals (CI) were calculated using unconditional logistic regression. RESULTS: There was a significant association between short interpregnancy interval and spontaneous early preterm delivery, both crude (OR=3.9; 95% CI: 1.91-8.10) and adjusted for maternal age, school education, previous birth outcomes, antenatal care, smoking habits, body mass index and gestational weight gain (adj(OR)=3.6; 95% CI: 1.41-8.98). No significant effect on spontaneous late preterm delivery was found (crude(OR)=0.8; 95% CI: 0.32-1.83). CONCLUSIONS: This study showed that short interpregnancy intervals significantly increased the risk of early spontaneous preterm birth but no such effect was evident for late preterm deliveries.     

Prospective observational study to determine the accuracy of first-trimester serum biomarkers and uterine artery Dopplers in combination with maternal characteristics and arteriography for the prediction of women at risk of preeclampsia and other adverse pregnancy outcomes

Objectives: To assess the efficacy of biomarkers, arteriography and uterine artery Dopplers for predicting hypertensive disease of pregnancy, small for gestational age (SGA) and stillbirth.

Methods: This was a prospective first-trimester study. Ultrasound was used to assess uterine artery Doppler. Maternal arteriography was performed and serum was taken for the measurement of placental growth factor (PlGF), alpha-fetoprotein (AFP), pregnancy-associated plasma protein (PAPP-A) and beta-human chorionic gonadotrophin levels. Logistic regression with stepwise selection was performed to determine multivariate models.

Results: One thousand and forty-five women were left for analysis after exclusions. Fourteen developed preeclampsia, 23 pregnancy induced hypertension, 64 SGA <5th centile, 118 SGA <10th centile and three stillbirth. Systolic blood pressure (SBP) in the aorta (SBPAO) (p?=?.002) was significantly associated with preeclampsia. Detection rate (DR) was 72% for a false-positive rate (FPR) of 15%, an area under the curve (AUC) of 0.81, 95% CI 0.69–0.93. MAP and maternal weight (p?=?.001) were significantly associated with PIH. DR 48%, AUC 0.76, 95% CI 0.65–0.86. Low PAPP-A and PlGF were significantly associated with SGA <10th centile (p?=?.007 and .004, respectively), DR 30%, AUC 0.608, 95% CI 0.54–0.68. SGA <5th centile was significantly associated with low PlGF (p?=?<.001), DR 57%, AUC 0.73, 95% CI 0.65–0.80.

Conclusions: No association was found between first-trimester biomarkers and preeclampsia/PIH. There was a significant association between low PlGF and PAPP-A and SGA.     

Events after Stillbirth in Relation to Maternal Depressive Symptoms: A Brief Report

ABSTRACT: Background: Actions taken after a stillbirth can affect long‐term psychological morbidity. Our objective was to study how infant bonding and maternal actions after stillbirth are associated with ensuing depressive symptoms. Methods: Using the population‐based Swedish Medical Birth Register, we identified all 380 Swedish‐speaking women who gave birth to singleton stillborn infants in Sweden in 1991. Of these, 314 (83%) completed a postal questionnaire 3 years after the stillbirth. Items included actions taken to bond with the baby and demographics. The association between care‐related factors and later maternal depressive symptoms was quantified using relative risks estimated using multivariable regression. Results: We observed an almost sevenfold increased risk of depressive symptoms for mothers who reported not being with their babies as long as they wished (adjusted risk ratio [RR] 6.9, 95% CI 2.4–19.8). Compared with women who became pregnant again within 6 months, those with no later pregnancy were at higher risk of depressive symptoms (adjusted RR 2.8, 95% CI 0.9–8.4). In addition, compared with women who experienced a stillbirth in their first pregnancy, stillbirth occurring with an infant who was third in the birth order was related to a twofold risk of elevated depressive symptoms (adjusted RR 2.2, 95% CI 0.8–6.4). Furthermore, stillbirth occurring in a fourth or later pregnancy was associated with an almost sevenfold risk of depressive symptomatology (adjusted RR 6.7, 95% CI 2.2–20.5). No evidence of an association was found between other care‐related actions and subsequent maternal depressive symptoms. Conclusions: Our results suggest that a mother being with the stillborn baby for as long as desired and the birth order of the stillbirth may influence her later depressive symptomatology. Compared with mothers who became pregnant again within 6 months, those who did not have a subsequent pregnancy were at higher risk of depressive symptoms at 3 years’ follow‐up. (BIRTH 35:2 June 2008)     

Working conditions and adverse pregnancy outcome: a meta-analysis

OBJECTIVE: To evaluate the association between working conditions and adverse pregnancy outcomes by performing a meta-analysis of published studies. DATA SOURCES: We searched the English-language literature in MEDLINE through August 1999 using the terms standing, posture, work, workload, working conditions, shift, occupational exposure, occupational diseases, lifting, pregnancy complications, pregnancy, small for gestational age (SGA), fetal growth retardation (FGR), preterm, and labor. METHODS OF STUDY SELECTION: We included observational studies evaluating the effect of one or more of the following work-related exposures on adverse pregnancy outcome: physically demanding work, prolonged standing, long work hours, shift work, and cumulative work fatigue score. Outcomes of interest were preterm birth, hypertension or preeclampsia, and SGA.We conducted a meta-analysis based on 160,988 women in 29 studies to evaluate the association of physically demanding work, prolonged standing, long working hours, shift work, and cumulative work fatigue score with preterm birth. Also analyzed were the associations of physically demanding work with hypertension or preeclampsia and SGA infants. The data were analyzed using the Peto-modified Mantel-Haenszel method to estimate the pooled odds ratios (ORs) and 95% confidence intervals (CIs). TABULATION, INTEGRATION, AND RESULTS: Physically demanding work was significantly associated with preterm birth (OR 1.22, 95% CI 1.16, 1. 29), SGA (OR 1.37, 95% CI 1.30, 1.44), and hypertension or preeclampsia (OR 1.60, 95% CI 1.30, 1.96). Other occupational exposures significantly associated with preterm birth included prolonged standing (OR 1.26, 95% CI 1.13, 1.40), shift and night work (OR 1.24, 95% CI 1.06, 1.46), and high cumulative work fatigue score (OR 1.63, 95% CI 1.33, 1.98). We found no significant association between long work hours and preterm birth (OR 1.03, 95% CI 0.92, 1.16). CONCLUSION: Physically demanding work may significantly increase a woman's risk of adverse pregnancy outcome.     

Pregnancy and delivery with an intrauterine device in situ: outcomes in the National Inpatient Sample Database

Background: Pregnancy with intrauterine device in place is rare and there are limited data that exist regarding associated perinatal outcomes.

Objective: The objective of this study is to determine the association between presence of an intrauterine device during pregnancy and spontaneous abortion, induced abortion, and preterm or small for gestational age delivery outcomes.

Study design: The National Inpatient Sample database was analyzed for the years 2010 and 2011. Maternal records with an intrauterine device in situ during delivery were identified using International Classification of Diseases, Ninth Revision, diagnostic codes. Primary outcome was incidence of spontaneous abortion. Secondary outcomes were incidence of induced abortion, preterm delivery, and small for gestational age. Data were analyzed using Chi-square and Fisher’s exact tests to calculate odds ratios (ORs) of abortion in association with intrauterine device in situ during pregnancy. Maternal birth records were further analyzed for adverse neonatal outcomes using logistic regression models, controlling for possible confounding variables.

Results: The data included 8,597,284 maternal birth records; 0.02% with an intrauterine device in situ. Patients with an intrauterine device in situ experienced a higher frequency of the pregnancy ending in spontaneous abortion (OR: 7.15; 95% confidence interval (CI): 5.06–10.09; p?p?in situ was 2.04 (95% CI: 1.71–2.43; p?p?=?.022), after controlling for associated demographic and clinical variables.

Conclusion: The presence of an intrauterine device in situ during pregnancy was associated with increased spontaneous and induced abortions, and increased incidence of delivery of a preterm, but not small for gestational age infant.     

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

ObjectiveTo determine the population-level impact of COVID-19 pandemic–related obstetric practice changes on maternal and newborn outcomes.MethodsSegmented regression analysis examined changes that occurred 240 weeks pre-pandemic through the first 32 weeks of the pandemic using data from Ontario’s Better Outcomes Registry & Network. Outcomes included birth location, length of stay, labour analgesia, mode of delivery, preterm birth, and stillbirth. Immediate and gradual effects were modelled with terms representing changes in intercepts and slopes, corresponding to the start of the pandemic.ResultsThere were 799 893 eligible pregnant individuals included in the analysis; 705 767 delivered in the pre-pandemic period and 94 126 during the pandemic wave 1 period. Significant immediate decreases were observed for hospital births (relative risk [RR] 0.99; 95% CI 0.98–0.99), length of stay (median change –3.29 h; 95% CI –3.81 to –2.77), use of nitrous oxide (RR 0.11; 95% CI 0.09–0.13) and general anesthesia (RR 0.69; 95% CI 0.58– 0.81), and trial of labour after cesarean (RR 0.89; 95% CI 0.83–0.96). Conversely, there were significant immediate increases in home births (RR 1.35; 95% CI 1.21–1.51), and use of epidural (RR 1.02; 95% CI 1.01–1.04) and regional anesthesia (RR 1.01; 95% CI 1.01–1.02). There were no significant immediate changes for any other outcomes, including preterm birth (RR 0.99; 95% CI 0.93–1.05) and stillbirth (RR 1.11; 95% CI 0.87–1.42).ConclusionProvincial health system changes implemented at the start of the pandemic resulted in immediate clinical practice changes but not insignificant increases in adverse outcomes.     

Adverse Pregnancy Outcomes Among Foreign-Born Canadians

ObjectiveNumerous non-Canadian studies have shown that immigrant women experience higher rates of adverse maternal and perinatal events than the general non-immigrant population. Limited information about the pregnancy outcomes of immigrant Canadian women is available.MethodsWe conducted a retrospective cohort study at St. Michael's Hospital between October 2002 and June 2006 to estimate the risk of adverse obstetrical and perinatal outcomes among foreign-born women residing in Toronto. The main study outcomes were the incidences of preterm delivery between 32 and 36 completed weeks’ gestation, low infant birth weight, and delivery by Caesarean section.ResultsCompared with Canadian-born women, those who were foreign-born had an associated adjusted odds ratio of 0.85 (95% CI 0.64 to 1.14) for preterm delivery, 1.92 (95% CI 1.29 to 2.85) for low infant birth weight, and 1.16 (95% CI 1.01 to 1.34) for delivery by Caesarean section.ConclusionIn this study, foreign-born women had a non-significantly lower risk of preterm birth, but a significantly higher risk of low birth weight infants and Caesarean section than Canadian-born women. In this urban setting, recent immigrant women have worse pregnancy outcomes, warranting increased attention to this group during antenatal and intrapartum care.     

Second-trimester maternal serum alpha-fetoprotein and risk of adverse pregnancy outcome(1)

OBJECTIVE: To determine the risk of adverse pregnancy outcome by maternal serum alpha-fetoprotein (MSAFP) level. METHODS: We followed 77,149 pregnant women and their infants from MSAFP screening in the 15th to 20th week of gestation until 1 year after birth. Information on pregnancy outcome was obtained from national registries. The relative risks (RRs) and 95% confidence intervals (CIs) for adverse pregnancy outcome were estimated according to the level of MSAFP, with adjustment for confounders. RESULTS: A total of 638 pregnancies resulted in spontaneous abortion, 289 in stillbirth, and 437 in infant death. Compared with women with MSAFP levels at 0.75-1.24 multiples of the median (MoM), those with MSAFP levels greater than or equal to 2.5 MoM had an increased risk of spontaneous abortion (RR 12.5; 95% CI 9.7, 16.1), preterm birth (RR 4.8; 95% CI 4.1, 5.5), small for gestational age (RR 2.8; 95% CI 2.4, 3.2), low birth weight (RR 5.8; 95% CI 5.0, 6.6), and infant death (RR 1.9; 95% CI 1.2, 2.8). Women with MSAFP levels below 0.25 MoM had an increased risk of spontaneous abortion (RR 15.1; 95% CI 9.3, 24.8), preterm birth (RR 2.2; 95% CI 1.3, 3.8), and stillbirth (RR 4.0; 95% CI 1.0, 16.0); those with levels less than 0.5 MoM had an increased risk of infant death (RR 1.9; 95% CI 1.2, 3.0). The increased risk of infant death remained after the subtraction of recognized conditions associated with extreme MSAFP values. CONCLUSION: Pregnant women with extreme MSAFP values in the second trimester have an increased risk of fetal and infant deaths. Obstet Gynecol 2001;97:277-82.     

Ethnicity-Specific Growth Distributions for Prediction of Newborn Morbidity

ObjectivesBirth weight distributions differ according to the ethnic origin of the mother. We aimed to determine whether using ethnicity-specific growth distributions would identify newborns at risk for adverse infant outcomes associated with small for gestational age (SGA) birth better than population-based distributions.MethodsWe examined 2647 singletons born to healthy non-smoking mothers at British Columbia Women’s Hospital at 37 to 41 completed weeks’ gestation. We compared the ability of ethnicityspecific growth distributions and population-based distributions to predict which infants were at increased risk of adverse outcomes associated with SGA, as well as extended length of stay in hospital,using crude and adjusted odds ratios.ResultsThe ethnicity-specific growth distributions were associated with an increased risk of adverse infant outcomes while the population-based distributions were not (adjusted odds ratio [aOR] 1.49 [95% CI 0.82 to 2.70] vs. aOR 0.88 [95% CI 0.48 to 1.64]). While both distributions predicted extended length of stay in hospital, this likely reflects clinicians’ use of the population-based distribution to identify SGA infantsConclusionThe use of ethnicity-specific growth distributions will likely improve our ability to differentiate between babies who are pathologically small and those who are constitutionally small, and prevent misclassification of constitutionally small but healthy newborns born to mothers of Chinese or South Asian descent as SGA.     

Outcomes of Planned Hospital Birth Attended by Midwives Compared with Physicians in British Columbia

ABSTRACT: Background: The impact of midwifery versus physician care on perinatal outcomes in a population of women planning birth in hospital has not yet been explored. We compared maternal and newborn outcomes between women planning hospital birth attended by a midwife versus a physician in British Columbia, Canada. Methods: All women planning a hospital birth attended by a midwife during the 2‐year study period who were of sufficiently low‐risk status to meet eligibility requirements for home birth as defined by the British Columbia College of Midwives were included in the study group (n =488). The comparison group included women meeting the same eligibility requirements but planning a physician‐attended birth in hospitals where midwives also practiced (n =572). Outcomes were ascertained from the British Columbia Reproductive Care Program Perinatal Registry to which all hospitals in the province submit data. Results: Adjusted odds ratios for women planning hospital birth attended by a midwife versus a physician were significantly reduced for exposure to cesarean section (OR 0.58, 95% CI 0.39–0.86), narcotic analgesia (OR 0.26, 95% CI 0.18–0.37), electronic fetal monitoring (OR 0.22, 95% CI 0.16–0.30), amniotomy (OR 0.74, 95% CI 0.56–0.98), and episiotomy (OR 0.62, 95% CI 0.42–0.93). The odds of adverse neonatal outcomes were not different between groups, with the exception of reduced use of drugs for resuscitation at birth (OR 0.19, 95% CI 0.04–0.83) in the midwifery group. Conclusions: A shift toward greater proportions of midwife‐attended births in hospitals could result in reduced rates of obstetric interventions, with similar rates of neonatal morbidity. (BIRTH 34:2 June 2007)