Deborah A. McNeil

The All Our Babies pregnancy cohort: design, methods, and participant characteristics.

BackgroundThe prospective cohort study design is ideal for examining diseases of public health importance, as its inherent temporal nature renders it advantageous for studying early life influences on health outcomes and research questions of aetiological significance. This paper will describe the development and characteristics of the All Our Babies (AOB) study, a prospective pregnancy cohort in Calgary, Alberta, Canada designed to examine determinants of maternal, infant, and child outcomes and identify barriers and facilitators in health care utilization.MethodsWomen were recruited from health care offices, communities, and through Calgary Laboratory Services before 25 weeks gestation from May 2008 to December 2010. Participants completed two questionnaires during pregnancy, a third at 4 months postpartum, and are currently being followed-up with questionnaires at 12, 24, and 36 months. Data was collected on pregnancy history, demographics, lifestyle, health care utilization, physical and mental health, parenting, and child developmental outcomes and milestones. In addition, biological/serological and genetic markers can be extracted from collected maternal and cord blood samples.ResultsA total of 4011 pregnant women were eligible for recruitment into the AOB study. Of this, 3388 women completed at least one survey. The majority of participants were less than 35 years of age, Caucasian, Canadian born, married or in a common-law relationship, well-educated, and reported household incomes above the Calgary median. Women who discontinued after the first survey (n=123) were typically younger, non-Caucasian, foreign-born, had lower education and household income levels, were less likely to be married or in a common-law relationship, and had poor psychosocial health in early pregnancy. In general, AOB participants reflect the pregnant and parenting population at local and provincial levels, and perinatal indicators from the study are comparable to perinatal surveillance data.ConclusionsThe extensive and rich data collected in the AOB cohort provides the opportunity to answer complex questions about the relationships between biology, early experiences, and developmental outcomes. This cohort will contribute to the understanding of the biologic mechanisms and social/environmental pathways underlying associations between early and later life outcomes, gene-environment interactions, and developmental trajectories among children.

Is there an association between spatial access to parks/green space and childhood overweight/obesity in Calgary, Canada?

BackgroundThe recent increase in childhood obesity is expected to add significantly to the prevalence of chronic diseases. We used multivariate multilevel analysis to examine associations between parks/green space and childhood overweight/obesity across communities in Calgary, Canada, a city characterized by intensified urban sprawl and high car use.MethodsBody Mass Index was calculated from measured height and weight data obtained from 6,772 children (mean age = 4.95 years) attending public health clinics for pre-school vaccinations. Each childs home postal code was geocoded using ESRI ArcGIS 9.2. We examined four measures of spatial access to parks/green space (based on Geographic Information Systems): 1) the number of parks/green spaces per 10,000 residents, 2) the area of parks/green space as a proportion of the total area within a community, 3) average distance to a park/green space, and 4) the proportion of parks/green space service area as a proportion of the total area within a community. Analyses were adjusted for dissemination area median family income (as a proxy for an individual childs family income) community-level education, and community-level proportion of visible minorities.ResultsIn general, parks/green space at the community level was not associated with overweight/obesity in Calgary, with the exception of a marginally significant effect whereby a moderate number of parks/green spaces per 10,000 residents was associated with lower odds of overweight/obesity. This effect was non-significant in adjusted analyses.ConclusionOur null findings may reflect the popularity of car travel in Calgary, Canada and suggest that the role built environment characteristics play in explaining health outcomes may differ depending on the type of urban environment being studied.

All Our Babies Cohort Study: recruitment of a cohort to predict women at risk of preterm birth through the examination of gene expression profiles and the environment

BackgroundPreterm birth is the leading cause of perinatal morbidity and mortality. Risk factors for preterm birth include a personal or familial history of preterm delivery, ethnicity and low socioeconomic status yet the ability to predict preterm delivery before the onset of preterm labour evades clinical practice. Evidence suggests that genetics may play a role in the multi-factorial pathophysiology of preterm birth. The All Our Babies Study is an on-going community based longitudinal cohort study that was designed to establish a cohort of women to investigate how a womens genetics and environment contribute to the pathophysiology of preterm birth. Specifically this study will examine the predictive potential of maternal leukocytes for predicting preterm birth in non-labouring women through the examination of gene expression profiles and gene-environment interactions.Methods/DesignCollaborations have been established between clinical lab services, the provincial health service provider and researchers to create an interdisciplinary study design for the All Our Babies Study. A birth cohort of 2000 women has been established to address this research question. Women provide informed consent for blood sample collection, linkage to medical records and complete questionnaires related to prenatal health, service utilization, social support, emotional and physical health, demographics, and breast and infant feeding. Maternal blood samples are collected in PAXgene™ RNA tubes between 18-22 and 28-32 weeks gestation for transcriptomic analyses.DiscussionThe All Our Babies Study is an example of how investment in clinical-academic-community partnerships can improve research efficiency and accelerate the recruitment and data collection phases of a study. Establishing these partnerships during the study design phase and maintaining these relationships through the duration of the study provides the unique opportunity to investigate the multi-causal factors of preterm birth. The overall All Our Babies Study results can potentially lead to healthier pregnancies, mothers, infants and children.

The Incidence of Positional Plagiocephaly: A Cohort Study

OBJECTIVE: The objective of this study was to estimate the incidence of positional plagiocephaly in infants 7 to 12 weeks of age who attend the 2-month well-child clinic in Calgary, Alberta, Canada. METHODS: A prospective cohort design was used to recruit 440 healthy full-term infants (born at ≥37 weeks of gestation) who presented at 2-month well-child clinics for public health nursing services (eg, immunization) in the city of Calgary, Alberta. The study was completed in 4 community health centers (CHCs) from July to September 2010. The CHCs were selected based on their location, each CHC representing 1 quadrant of the city. Argentas (2004) plagiocephaly assessment tool was used to identify the presence or absence of plagiocephaly. RESULTS: Of the 440 infants assessed, 205 were observed to have some form of plagiocephaly. The incidence of plagiocephaly in infants at 7 to 12 weeks of age was estimated to be 46.6%. Of all infants with plagiocephaly, 63.2% were affected on the right side and 78.3% had a mild form. CONCLUSIONS: To our knowledge, this is the first population-based study to investigate the incidence of positional plagiocephaly using 4 community-based data collection sites. Future studies are required to corroborate the findings of our study. Research is required to assess the incidence of plagiocephaly using Argentas plagiocephaly assessment tool across more CHCs and to assess prevalence at different infant age groups. The utility of using Argentas plagiocephaly assessment tool by public health nurses and/or family physicians needs to be established.

A qualitative study of the experience of CenteringPregnancy group prenatal care for physicians

BackgroundThis study sought to understand the central meaning of the experience of group prenatal care for physicians who were involved in providing CenteringPregnancy through a maternity clinic in Calgary, Canada.MethodThe study followed the phenomenological qualitative tradition. Three physicians involved in group prenatal care participated in a one-on-one interview between November and December 2009. Two physicians participated in verification sessions. Interviews followed an open ended general guide and were audio recorded and transcribed. The purpose of the analysis was to identify meaning themes and the core meaning experienced by the physicians.ResultsSix themes emerged: (1) having a greater exchange of information, (2) getting to knowing, (3) seeing women get to know and support each other, (4) sharing ownership of care, (5) having more time, and (6) experiencing enjoyment and satisfaction in providing care. These themes contributed to the core meaning for physicians of “providing richer care.”ConclusionsPhysicians perceived providing better care and a better professional experience through CenteringPregnancy compared to their experience of individual prenatal care. Thus, CenteringPregnancy could improve work place satisfaction, increase retention of providers in maternity care, and improve health care for women.

Comparing CenteringPregnancy® to standard prenatal care plus prenatal education.

BackgroundThere is significant evidence to support the importance of prenatal care in preventing adverse outcomes such as preterm birth and low infant birth weight. Previous studies have indicated that the benefits of prenatal care are not evenly distributed throughout the social strata. In addition, emerging evidence suggests that among particular populations, rates of preterm birth are unchanged or increasing. This suggests that an alternate care model is necessary, one that seeks to addresses some of the myriad of social factors that also contribute to adverse birth outcomes. In previous studies, the group prenatal care model CenteringPregnancy® had been shown to reduce adverse birth outcomes, but to date, no comparison had been made with a model that included prenatal education. This study sought to investigate whether any significant difference remained within the comparison groups when both models accounted for social factors.MethodsThis analysis was based on survey data collected from a prospective cohort of pregnant women through the All Our Babies Study in Calgary, Alberta.ResultsAt baseline, there were significant differences between the comparison groups in their psychosocial health, with the women in the CenteringPregnancy® group scoring higher levels of depressive symptoms, stress and anxiety. At four months postpartum, the differences between the groups were no longer significant. Conclusions: These results suggest that CenteringPregnancy® can recruit and retain a demographically vulnerable group of women with a constellation of risk factors for poor pregnancy and birth outcomes, including poverty, language barriers and poor mental health. Post program, the rates of stress, anxiety and depression were similar to other women with more social and financial advantage. These findings suggest that CenteringPregnancy® may be a community based care strategy that contributes to improved mental health, knowledge, and behaviours to optimize outcomes for mothers and children.

Pregnancy-related anxiety: A concept analysis

OBJECTIVES Evidence suggests that pregnancy-related anxiety is more strongly associated with maternal and child outcomes than general anxiety and depression are and that pregnancy-related anxiety may constitute a distinct concept. However, because of its poor conceptualization, the measurement and assessment of pregnancy-related anxiety have been limited. Efforts to analyze this concept can significantly contribute to its theoretical development. The first objective of this paper was to clarify the concept of pregnancy-related anxiety and identify its characteristics and dimensions. The second aim was to examine the items of current pregnancy-related anxiety measures to determine the dimensions and attributes that each scale addresses, noting any gaps between the current assessment and the construct of the concept. DESIGN A concept analysis was conducted to examine the concept of pregnancy-related anxiety. DATA SOURCES To obtain the relevant evidence, several databases were searched including MEDLINE, PsycINFO, EBSCOs SocINDEX, Psychological and Behavioral Sciences Collection, CINAHL, SCOPUS, and EMBASE. REVIEW METHODS A modified approach based on Walker and Avant (Strategies for theory construction in nursing. 5th ed; 2011) was used. Qualitative or quantitative studies published in English that explored or examined anxiety during pregnancy or its dimensions prospectively or retrospectively were included. RESULTS Thirty eight studies provided data for the concept analysis. Three critical attributes (i.e., affective responses, cognitions, and somatic symptoms), three antecedents (i.e., a real or anticipated threat to pregnancy or its outcomes, low perceived control, and excessive cognitive activity, and four consequences (i.e., negative attitudes, difficulty concentrating, excessive reassurance-seeking behavior, and avoidance behaviors) were identified. Nine dimensions for pregnancy-related anxiety were determined, and a definition of the concept was proposed. The most frequently reported dimensions included anxiety about fetal health, fetal loss, childbirth, and parenting and newborn care. The content of five scales was analyzed to determine the attributes and dimensions measured by each tool. Our findings suggest that the Pregnancy-Related Anxiety Scale tapping five dimensions of pregnancy-related anxiety and the Pregnancy Outcome Questionnaire with six items pertaining to the consequences of pregnancy-related anxiety can respectively be considered the most useful tools for assessing the existence and severity of the concept. CONCLUSIONS The critical attributes of pregnancy-related anxiety are similar to those defined for anxiety disorders. However, the behavioral consequences of pregnancy-related anxiety appear to apply only some women and may serve as important indicators of the severity of the condition. Current tools are useful instruments to determine whether the concept exists and to capture selected domains of pregnancy-related anxiety. A tool that includes all dimensions of the concept and examines the severity of pregnancy-related anxiety is needed.

Social equity in Human Papillomavirus vaccination: a natural experiment in Calgary Canada.

BackgroundThe Alberta Immunization Program offers a vaccine against the Human Papillomavirus (HPV) free of charge to all girls in Grades 5 and 9. The vaccine is provided in two different service delivery models depending upon the acceptance of the program by the local school board. Vaccinations may be provided “in-school” or in “community” through appointments at Public Health Clinics. The purpose of this study was to determine whether there was a difference in vaccine uptake in Calgary between the two service delivery models, “in-school” and “community”, and to examine if socioeconomic status (SES) was a contributing factor.MethodsIndividual data from the Calgary Zone Public Health vaccination database for all grade 5 and 9 girls in Calgary for school years 2008–2011 were analyzed using descriptive statistics. These data included vaccination records for 35,592 girls. Logistic regression was used to examine the effect of delivery system and SES status on being vaccinated, controlling for school type.ResultsHPV vaccination completion rates were 75% (95% confidence interval = 74.7%, 75.8%) for girls with an “in-school” compared to 36% (95% confidence interval = 35.3%, 37.2%) for girls in schools with a “community” service delivery model. A girl’s neighbourhood SES was related to the likelihood of being HPV vaccinated depending on the service delivery model available to her. For girls attending a Public school with an “in-school” delivery model, the proportion completing vaccination increased as SES decreased (high SES = 79%; medium SES = 79%; low SES = 83%; p-value<0.001). For girls attending Calgary Catholic School District schools with the “community” delivery model there was a decrease in immunization rates from high and mid to low SES (high SES = 41%; medium SES = 42%; low SES = 34%; p-value<0.001). These results show that those with lower SES were differentially disadvantaged by not having access to an “in-school” vaccination delivery model.ConclusionService delivery models make a difference in HPV vaccination completion rates and create inequities for health protection and disease prevention based on socioeconomic status.

Connecting Children to Recreational Activities: Results of a Cluster Randomized Trial

Purpose. Identify if outreach support increases school-aged childrens participation in recreational activities. Design. Cluster randomized trial. Setting. Sixteen schools in economically vulnerable neighborhoods were randomized to either an intervention or control group. Subjects. Children in grades 3 to 5 and their families were invited to participate. Intervention. Children in intervention schools were assigned a “connector” (outreach worker) to facilitate participation in recreation activities. Measures. The Childrens Assessment of Participation and Enjoyment (CAPE) was the primary measure at baseline, middle, and end of 1 year. Demographics, body mass index, child physical and psychosocial health, coordination, and self-esteem were measured. Analysis. A generalized linear model was used to test differences between intervention and control groups. Results. Three hundred and sixty children enrolled, and 306 (85 %) completed the study. A greater proportion of children in the intervention group compared with the control group increased participation in physical activity (21 % vs. 10%, p = .02). Children who increased their activity were more likely to have higher levels of contact with the connectors (31 % vs. 8%, p = .001). Study limitations included (I) 29% of eligible families participated, (2) first use of the CAPE instrument as a longitudinal measure, and (3) connectors were not blinded to group assignment. Conclusion. Children living in vulnerable neighborhoods benefit from outreach workers to connect them with physical activity programs.

Maternal work in the NICU: A Case Study of an “NICU-Experienced” Mother

This study explored one womans experience in becoming a mother to her premature son during his prolonged hospitalization. This paradigm case is an exemplar selected from a larger phenomenological study that examined the high-risk perinatal experience. Hermeneutic analysis led to the discovery of the phenomenon of maternal work embedded in the experience of this mother. Dimensions of her maternal work included working for love, working for meaningful moments, working amid uncertainty, working against the odds, and working overtime. Understanding the experience of maternal work can assist nurses to acknowledge and support the work inherent in becoming a mother within the neonatal intensive care unit.