Maternal Health

 

 

Maternal whole blood gene expression at 18 and 28 weeks of gestation associated with spontaneous preterm birth in asymptomatic women

Yujing J. Heng, Craig E. Pennell, Sheila W. McDonald, Angela E. Vinturache, Jingxiong Xu, Mary W. F. Lee, Laurent Briollais, Andrew W. Lyon, Donna M. Slater, Alan D. Bocking, Lawrence de Koning, David M.  Olson, Siobhan M. Dolan, Suzanne C. Tough, Stephen J. Lye

 

The heterogeneity of spontaneous preterm birth (SPTB) requires an interdisciplinary approach to determine potential predictive risk factors of early delivery. The aim of this study was to investigate maternal whole blood gene expression profiles associated with spontaneous preterm birth (SPTB, <37 weeks) in asymptomatic pregnant women. The study population was a matched subgroup of women (51 SPTBs, 114 term delivery controls) who participated in the All Our Babies community based cohort in Calgary (n = 1878). Maternal blood at 17–23 (sampling time point 1, T1) and 27–33 weeks of gestation (T2) were collected. Total RNA was extracted and microarray was performed on 326 samples (165 women). Univariate analyses determined significant clinical factors and differential gene expression associated with SPTB. Thirteen genes were validated using qRT-PCR. Three multivariate logistic models were constructed to identify gene expression at T1 (Model A), T2 (Model B), and gene expression fold change from T1 to T2 (Model C) associated with SPTB. All models were adjusted for clinical factors. Model C can predict SPTB with 65% sensitivity and 88% specificity in asymptomatic women after adjusting for history of abortion and anaemia (occurring before T2). Clinical data enhanced the sensitivity of the Models to predict SPTB. In conclusion, clinical factors and whole blood gene expression are associated with SPTB in asymptomatic women. An effective screening tool for SPTB during pregnancy would enable targeted preventive approaches and personalised antenatal care.

The impact of caesarean section on breastfeeding initiation, duration and difficulties in the first four months postpartum

Amy J. Hobbs, Cynthia A. Mannion, Sheila W. McDonald, Meredith Brockway and Suzanne C. Tough

 

Background: The caesarean section (c-section) rate in Canada is 27.1 %, well above the 5–15 % of deliveries suggested by the World Health Organization in 2009. Emergency and planned c-sections may adversely affect breastfeeding initiation, milk supply and infant breastfeeding receptivity compared to vaginal deliveries. Our study examined mode of delivery and breastfeeding initiation, duration, and difficulties reported by mothers at 4 months postpartum.

Methods: The All Our Babies study is a prospective pregnancy cohort in Calgary, Alberta, that began in 2008. Participants completed questionnaires at <25 and 34–36 weeks gestation and approximately 4 months postpartum. Demographic, mental health, lifestyle, and health services data were obtained. Women giving birth to singleton infants were included (n = 3021). Breastfeeding rates and difficulties according to mode of birth (vaginal, planned c-section and emergency c-section) were compared using cross-tabulations and chi-square tests. A multivariable logistic regression model was created to examine the association between mode of birth on breastfeeding duration to 12 weeks postpartum.

Results: More women who delivered by planned c-section had no intention to breastfeed or did not initiate breastfeeding (7.4 % and 4.3 % respectively), when compared to women with vaginal births (3.4 % and 1.8 %, respectively) and emergency c-section (2.7 % and 2.5 %, respectively). Women who delivered by emergency c-section were found to have a higher proportion of breastfeeding difficulties (41 %), and used more resources before (67 %) and after (58 %) leaving the hospital, when compared to vaginal delivery (29 %, 40 %, and 52 %, respectively) or planned c-sections (33 %, 49 %, and 41 %, respectively). Women who delivered with a planned c-section were more likely (OR = 1.61; 95 % CI: 1.14, 2.26; p = 0.014) to discontinue breastfeeding before 12 weeks postpartum compared to those who delivered vaginally, controlling for income, education, parity, preterm birth, maternal physical and mental health, ethnicity and breastfeeding difficulties.

Conclusions: We found that when controlling for socio-demographic and labor and delivery characteristics, planned c-section is associated with early breastfeeding cessation. Anticipatory guidance around breastfeeding could be provided to women considering a planned c-section. As well, additional supportive care could be made available to lactating women with emergency c-sections, within the first 24 hours post birth and throughout the early postpartum period.

Pre-pregnancy body mass index (BMI) and macrosomia in a Canadian birth cohort

Angela E. Vinturache, Kathleen H. Chaput & Suzanne C. Tough

 

Objective: To compare demographic characteristics and maternal, fetal, neonatal, and pregnancy outcomes of term macrosomic infants of obese and non-obese mothers.

Methods: A sample of 1996 singleton, term deliveries was drawn from the All Our Babies Cohort, a prospective, community-based pregnancy cohort. Maternal self-reported socio-demographic and anthropometric information was linked to the clinical data on pregnancy and birth events abstracted from electronic health records. Demographic, obstetrical characteristics and maternal, fetal, neonatal, and pregnancy outcomes of macrosomic infants in obese, overweight, and normal weight women were compared. Multinomial regression analysis assessed the risk factors of macrosomia in primiparous and multiparous women stratified by maternal prepregnancy BMI, controlling for confounding variables.

Results: Macrosomia affected 10% of pregnancies in the study. Mothers whose infants were macrosomic were more likely to be Caucasian, obese, have had previous deliveries, undergo induction of labour and delivery by emergency C-section, particularly for labour abnormalities. Macrosomic infants were more likely to be delivered postdates, have meconium stained liquor and require resuscitation at birth. There were no significant differences in birth and neonatal outcomes of macrosomic pregnancies between obese, overweight and normal weight women. Pre-pregnancy BMI and gestational age at delivery were risk factors for macrosomia in all women. Ethnicity and history of delivery of a macrosomic infant were additional independent risk factors in multiparas.

Conclusions: Obesity in pregnancy increases the risk of delivery of a macrosomic infant in both primiparous and multiparous women. The maternal, fetal and neonatal outcomes of macrosomic pregnancies are similar in obese and normal weight women

Exploring the relationship between socioeconomic factors, method of contraception and unintended pregnancy

Amy Metcalfe, Rachel Talavlikar, Beatrice du Prey and Suzanne C. Tough

 

Background: It is estimated that approximately one-third of pregnancies in Canada are unintended, meaning they were either mistimed (the woman wanted to be pregnant at a different point in time) or undesired (the woman did not want to be pregnant). This study aimed to assess the impact of socioeconomic variables and method of contraception on the decision to either terminate or continue and unintended pregnancy.

Methods: Data were obtained from two contemporaneous studies in Calgary Canada — a cross-sectional study involving women seeking abortion services (n = 577) and a longitudinal cohort study involving women with continuing pregnancies (n = 3552) between 2008 and 2012. Chi square tests and logistic regression were used to examine the association between socioeconomic variables, use of contraception and pregnancy intention.

Results: 96.5% of women seeking an abortion and 19.6% of women with ongoing pregnancies reported having an unintended pregnancy. Women with unintended pregnancies were significantly younger (p < 0.001), less educated (p < 0.001), had a lower household income (p < 0.001), were less likely to be in a stable relationship (p < 0.001), and less likely to speak English in the home (p < 0.002). 20.2% reported not using any form of birth control despite their desire to not get pregnant. Among women with unintended pregnancies, the only significant demographic predictor of not using any form of contraception was low educational attainment (OR = 1.7, 95 % CI: 1.2–2.4).

Conclusions: Low educational attainment was associated with not using any form of contraception among women with unintended pregnancies. However, as unintended pregnancy occurs across all socio-demographic groups, care providers are encouraged to have an open discussion regarding fertility goals and contraception with all patients and refer them to appropriate resource materials.

 

Health-related quality of life in pregnancy and postpartum among women with assisted conception in Canada.

Angela Vinturache, Nikki Stephenson, Sheila McDonald, Muci Wu, Hamideh Bayrampour & Suzanne Tough

 

Objective: To study the effects of mode of conception (spontaneous vs. assisted) on health-related quality of life (HRQoL) throughout pregnancy and in the postpartum period. Design: Secondary analysis of data from the All Our Babies cohort.

Patient(s): A total of 243 women with assisted conception and 3,309 women with spontaneous conception.

Intervention(s): Short Form 12 (SF-12) health survey administered by means of questionnaires at <25 weeks, 34–36 weeks of gestation, and 4 months postpartum.

Main Outcome Measure(s): Changes in the SF-12 Physical (PCS) and Mental (MCS) Component Summary scores from pregnancy to postpartum.

Result(s): The PCS scores were lower during pregnancy and at <25 weeks and 34–36 weeks of gestation among women with assisted conception, but were equivalent to those of women with spontaneous conception by 4 months postpartum. The MCS scores were higher at <25 weeks among women with assisted conception, but by 34–36 weeks of gestation and at 4 months postpartum they were similar regardless of the method of conception. Analysis of covariance showed no significant differences for the changes in PCS and MCS scores from pregnancy to postpartum between assisted and spontaneous conception groups, after adjusting for covariates.

Conclusion(s): Women with assisted conception may report lower physical and better mental health during pregnancy than women with spontaneous conception. At 4 months postpartum, there were no differences in self-reported HRQoL between modes of conception. Women with assisted conception may benefit from support and reassurance that perception of suboptimal health may improve over pregnancy and into the postpartum period

 

The influence of back pain and urinary incontinence on daily tasks of mothers at 12 months postpartum

Cynthia A. Mannion, Angela Vinturache, Sheila McDonald & Suzanne Tough

 

Objective: The present study examined back pain (BP) and/or urinary incontinence (UI) impact on the ability to perform daily tasks at 12 months after childbirth in healthy reproductive women who sought maternity care in community based family practice clinics.

Methods: This study is a secondary analysis from the All Our Babies Study, a prospective, community-based pregnancy cohort in Calgary, Alberta. Maternal self-reported information on demographics, lifestyle, experiences with pregnancy and childbirth, occurrence of BP, UI and consequent impairment of daily tasks were collected by questionnaires administered before 25 weeks, at 34-36 weeks gestation and at 4 and 12 months postpartum. The occurrence and severity of BP and UI at one year after childbirth was assessed using descriptive and bivariate analyses. Logistic regression models examined the association between demographic and obstetrical variables and the severity of functional impairment due to UI and BP.

Results: From 1574 women with singleton pregnancies included in the study, 1212 (77%) experienced BP, 773 (49%) UI, and 620 (40%) both BP and UI. From the 821 women reporting impairment of daily tasks due to BP, 199 (24 %) were moderately and 90 (11%) severely affected with the remainder, 532 (64%) being mildly affected. From 267 women with functional impairment due to UI, 52 (19%) reported moderately to severe impairment in their ability to perform daily tasks. Obesity and parity were risk factors for impairment of daily functioning due to BP, whereas obesity and vaginal delivery increased the risk of moderate to severe impairment due to UI.

Conclusions: BP and UI are common occurrences 1 year after childbirth. Maternal performance of daily tasks and women’s health and quality of life are more often impaired due to BP than UI. Our study brings new evidence of the risk factors that predict severity and impact of these conditions on women functioning at 12 months postpartum.

Perinatal outcomes of maternal overweight and obesity in term infants: a population-based cohort study in Canada

Angela Elena Vinturache, Sheila McDonald, Donna Slater and Suzanne Tough

 

The objective of this study was to assess the impact of increased pre-pregnancy maternal body mass index (BMI) on perinatal outcomes in term, singleton pregnancies who received prenatal care in community-based practices. The sample of 1996 infants included in the study was drawn from the All Our Babies Study, a prospective pregnancy cohort from Calgary. Multivariable logistic regression explored the relationship between the main outcomes, infant birth weight, Apgar score, admission to neonatal intensive care (NICU) and newborn duration of hospitalization, and BMI prior to pregnancy. Approximately 10% of the infants were macrosoms, 1.5% had a low Apgar score (<7 at 5 min), 6% were admitted to intensive care and 96% were discharged within 48 h after delivery. Although the infants of overweight and obese women were more likely to have increased birth weight as compared to infants of normal weight women, there were no differences in Apgar score, admission to NICU, or length of postnatal hospital stay among groups. This study suggests that in otherwise healthy term, singleton pregnancies, obesity does not seem to increase the risk of severe fetal impairment, neonatal admission to intensive care or duration of postnatal hospitalization.

Characteristics of women who consume alcohol before and after pregnancy recognition in a Canadian sample: a prospective cohort study

Sheila W. McDonald, Matthew Hicks, Carmen Rasmussen, Tharsiya Nagulesapillai, Jocelynn Cook and Suzanne C. Tough

 

Background: High levels of alcohol consumption during pregnancy are teratogenic to fetal development, yet less is known about the effects of low levels of consumption. Only a few studies have reported on the predictors and maternal characteristics associated with different alcohol consumption patterns prior to and following pregnancy recognition.

Methods: The All Our Babies longitudinal study in Alberta, Canada was used to analyze the association of maternal characteristics with binge drinking prior to pregnancy recognition and low to moderate levels after pregnancy recognition among 2,246 women who consumed alcohol 1 year prior to pregnancy. Bivariate and multivariable analyses were conducted.

Results: Thirteen percent of women reported binge drinking prior to pregnancy recognition. Forty-six percent reported drinking after pregnancy recognition, almost all at low to moderate levels. Significant, independent predictors (odds ratio, 95% confidence interval) of binge drinking in early pregnancy included high school or less education (3.61, 1.81 to 7.19), some or completed university/college (2.23, 1.16 to 4.27), nulliparity (1.62, 1.19, 2.20), not trying to get pregnant (1.92, 1.37 to 2.69), smoked in the year prior to pregnancy (1.98, 1.43 to 2.73), binge drinking in the year prior to pregnancy (10.83, 6.71 to 17.46), and low dispositional optimism (1.73, 1.23 to 2.42). Independent predictors of low to moderate average levels of consumption after pregnancy recognition included not trying to get pregnant (1.91, 1.45 to 2.52), prepregnancy body mass index <25.0 kg/m2 (1.41, 1.61 to 1.72), smoking in the year before pregnancy (1.90, 1.43 to 2.53), and binge drinking in the year before pregnancy (2.62, 2.16 to 3.18).

Conclusions: Common risk factors for different alcohol consumption patterns are unintended pregnancy and substance use behaviors prior to pregnancy. Other risk factors were specific to the different patterns. Targeted strategies that address the needs of alcohol or nicotine using women and that can reduce the risk of unintended pregnancy may be beneficial.

Pre-pregnancy Body Mass Index (BMI) and delivery outcomes in a Canadian population

Angela Vinturache, Nadia Moledina, Sheila McDonald, Donna Slater and Suzanne Tough

 

Background: Worldwide there has been a dramatic increase in the prevalence of overweight and obesity in women of childbearing age. Growing evidence suggests that maternal overweight and obesity is associated with poor maternal and perinatal outcomes. This study evaluated the impact of maternal pre-pregnancy overweight and obesity on pregnancy, labour and delivery outcomes in a cohort of women with term, singleton pregnancies cared for by family physicians in community based practices.

Methods: This study is a secondary analysis of the All Our Babies Cohort, a prospective, community-based pregnancy cohort in Calgary, Alberta. Maternal self-reported data on height and pre-pregnancy weight from term, singleton, cephalic pregnancies (n = 1996) were linked to clinical data on pregnancy and birth events retrieved from electronic health records. Descriptive and bivariate regression analysis were used to compare pregnancy and birth outcomes between women categorized as normal weight, overweight and obese based on the pre-pregnancy BMI. Multinomial regression analysis stratified by type of labour onset examined the association between pre-pregnancy BMI and mode of delivery controlling for maternal age, pre-existent health conditions, parity, fertility treatments, history of C-section and pregnancy complications.

Results: The cohort consisted of 65.8% normal weight, 23.6% overweight and 10.6% obese women. Women with increased pre-pregnancy BMI were more likely to develop pregnancy complications such as preeclampsia (OR 3.5, CI 2.0-4.6 for overweight; OR 5.3, CI 3.3-8.5 for obese) and gestational diabetes (OR 3.0, CI 1.8-5.0 for overweight; OR 6.5, CI 3.7-11.2 for obese) than normal weight women. Spontaneous onset of labour was recorded in 71.2% of women with normal pre-pregnancy BMI, whereas 39.3% of overweight and 49% of obese women had their labour induced. For women with spontaneous labour, pre-pregnancy BMI was not a significant risk factor for mode of delivery, controlling for covariates. Among women with induced labor, obesity was a significant risk factor for delivery by C-section (adjusted OR 2.2; CI 1.2-4.1).

Conclusions: Even among women with term, singleton pregnancies obtaining prenatal care in community-based settings, obese women who undergo labour induction are at increased risk of obstetrical interventions at delivery. These findings highlight the importance of tailored maternal care in pregnancy and at delivery of pregnant women with increased BMI in order to improve the outcomes and wellbeing of these women and their children.

Breastfeeding difficulties and exclusivity among late preterm and term infants: results from the All Our Babies Study

Tharsiya Nagulesapillai, Sheila W. McDonald, Tanis R. Fenton, Hannah Faye G. Mercader and Suzanne C. Tough

 

OBJECTIVE: To compare breastfeeding difficulties attributable to the baby and mother/milk and exclusive breastfeeding between a group of late preterm (LP) infants and term infants.

METHODS: We utilized data from a prospective community-based cohort (n=2977) in Calgary, Alberta, and performed bivariate and multivariable analyses to identify demographic, obstetric, maternal and infant health indicators that were independently associated with term status and breastfeeding outcomes.

RESULTS: Multivariable analyses found that LP status was an independent risk factor for breastfeeding difficulties attributable to the baby (OR 1.72, 95% CI 1.24-2.38), but not for difficulties due to mother/milk (defined as not producing enough milk or having flat or inverted nipples). Among women who were breastfeeding at hospital discharge, mothers of LP infants were less likely to report exclusive breastfeeding at 4 months (OR 0.67, 95% CI 0.46-0.97), after controlling for household income level, mode of delivery and postpartum maternal physical health.

CONCLUSIONS: Mothers of LP infants need increased support to establish successful breastfeeding outcomes and to ensure that these infants receive the full benefits of breast milk.

Maternal perceptions of partner support during breastfeeding

Cynthia A. Mannion, Amy J. Hobbs, Sheila W. McDonald and Suzanne C. Tough

 

Background: Many women find breastfeeding challenging to sustain beyond the first three postpartum months. Women rely on a variety of resources to aid and encourage breastfeeding, including ‘partner support’. Women’s perception of partner support during breastfeeding may influence maternal satisfaction and confidence but it remains understudied. We asked women about their perceptions of partner support during breastfeeding and measured the effect on maternal confidence, commitment, and satisfaction with respect to breastfeeding.

Methods: Using a descriptive, cross sectional design, we recruited 76 mothers from community health clinics in Calgary, Alberta. Participants completed a questionnaire addressing perceptions of partner support, the Breastfeeding Self-Efficacy Scale (BSES) measuring maternal confidence and ability to breastfeed, and the Hill and Humenick Lactation Scale (HHLS) measuring commitment, perceived infant satiety, and breastfeeding satisfaction. Descriptive analysis was performed on socio-demographic and survey responses. Multiple regression modeling was used to examine the association between partner support and breastfeeding outcomes.

Results: Women who reported active/positive support from their partners scored higher on the BSES (p < 0.019) than those reporting ambivalent/negative partner support when we controlled for previous breastfeeding experience and age of infant. There were no significant differences between the two groups of women on total score of HHLS or any of the subscales with respect to perceptions of partner support.

Conclusion: Mothers feel more capable and confident about breastfeeding when they perceive their partners are supportive by way of verbal encouragement and active involvement in breastfeeding activities. Mothers with partners who seemed ambivalent, motivated only by “what’s best for baby,” or provided negative feedback about breastfeeding, felt less confident in their ability to breastfeed. It is important that health care professionals appreciate the influence that positive and active partner support has upon the development of maternal confidence in breastfeeding, a known predictor for maintaining breastfeeding. Common support strategies could be communicated to both the partner and mother in the prenatal and postpartum periods. Health professionals can provide information, invite partners to become active learners and discuss supportive partner functions. Further research should address those functions that are perceived as most supportive by mothers and that partners are willing to perform.

Exclusive breastfeeding and assisted reproductive technologies: a Calgary cohort

Candace O’Quinn, Amy Metcalfe, Sheila W. McDonald, Nikolett Raguz and Suzanne C. Tough

 

Objectives: To determine if there is a difference in exclusive breastfeeding rates between mothers who conceived spontaneously compared with those who conceived using Artificial Reproductive Technology (ART).

Study methods: A prospective cohort study (“All Our Babies”) of pregnant women was conducted in Calgary, Alberta, Canada from May 2008-May 2010. Participants completed three written questionnaires, two during pregnancy and one at four months postpartum. Data for this analysis included all participants who used ART to conceive the pregnancy, and a 2:1 random selection of women who conceived spontaneously. ART included use of fertility enhancing drugs and/or artificial insemination and/or in vitro fertilization +/- intra cytoplasmic sperm injection. Descriptive statistics were used to characterize the population. Chi square tests, Fisher exact tests and t-tests were used to assess differences between groups.

Results: Seventy-six participants (5.9%) used some form of ART to conceive. Mothers in the group who used ART to conceive were older than the group who conceived spontaneously (p=0.001). At four months post-partum 54.1% of infants who were conceived via ART were exclusively breastfed compared to 59.7% of infants who were spontaneously conceived (p=0.99). No significant differences in terms of breastfeeding initiation (p=0.60), breastfeeding at 4 months postpartum (p=0.20) or breastfeeding difficulties (p=0.65) were found between women who conceived spontaneously and women who conceived through ART.

Conclusion: This study suggests that mothers who conceive using ART do not differ from those who conceived spontaneously in breastfeeding initiation, duration or likelihood of difficulty. This suggests that specialized counseling for these mothers is not required in regards to breastfeeding and these mothers can be reassured that using ART to conceive will not impact their breastfeeding practices.

 

 

Utilization of the 2009 H1N1 vaccine by pregnant women in a pandemic year

Sara Gracie, Amy Metcalfe, Siobhan M. Dolan, Heather Kehler, Jodi Siever & Suzanne Tough

 

Objective: To determine the proportion of pregnant women in a community-based cohort who received the H1N1 vaccine during the 2009–2010 influenza pandemic, and to identify sociodemographic factors that were associated with receiving the vaccine.

Methods: Women in Alberta from a cross-sectional communitybased cohort who were participating in a study of prenatal care were asked about their receipt of the 2009 H1N1 and seasonal influenza vaccines and whether they had contracted influenza. Univariable and backwards multivariable logistic regression were used to identify the sociodemographic factors associated with receiving the 2009 H1N1 vaccine.

Results: Approximately 72% of women in this sample (n = 402) received an influenza vaccine in 2009; 29.4% received both H1N1 and seasonal influenza vaccines, 40.8% received only the 2009 H1N1 vaccine, 1.7% received only the seasonal influenza vaccine, and 28.1% did not receive either vaccine. Univariable analysis found that receiving the 2009 H1N1 vaccine was significantly associated with household income, education, current employment status, and contentment about the pregnancy. After multivariable analysis, education and having a planned pregnancy remained as independent predictors of vaccination status.

Conclusion: During the 2009–2010 pandemic influenza season, over 70% of this cohort received influenza vaccinations, a much higher proportion than seen in previous influenza seasons. The majority of women who received the 2009 H1N1 vaccine were likely influenced by the increased media attention given to the 2009–2010 pandemic and the replacement of seasonal vaccine by the 2009 H1N1 vaccine