Nathan C. Nickel

The extent that noncompliance with the ten steps to successful breastfeeding influences breastfeeding duration

Background, Objectives: The Ten Steps to Successful Breastfeeding are not, as yet, the norm in the United States. This study examined how noncompliance with each of the Steps, and combinations of 2 Steps, influence duration of breastfeeding at the breast. Methods: Data were from the national Infant Feeding Practices Study II. The outcome was duration of any breastfeeding at the breast. Propensity scores modeled the probability of exposure to lacking 1 or more of the Ten Steps. Inverse probability weights controlled for confounding. Survival analyses estimated the relationship between the lack of a Step and breastfeeding duration. Results: Lack of Step 6 (No human milk substitutes) was associated with shorter breastfeeding duration, compared with being exposed to Step 6 (10.5-wk decrease). Lack of both Steps 4 (Breastfeed within 1 hour after birth) and 9 (Pacifiers), together, was related to the greatest decrease in breastfeeding duration (11.8-wk decrease). The findings supported a dose-response relationship: being exposed to 6 Steps was related to the longest median duration (48.8 wk), followed by 4 or 5 Steps (39.8 wk), followed by 2 or 3 Steps (36.4 wk). Conclusions: Prevalent US maternity care practices do not, as yet, include all of the Ten Steps. This lack of care may be associated with poor establishment of the physiological feedback systems that support sustained breastfeeding. Breastfeeding at the breast is compromised when specific combinations of Steps are lacking. Efforts to increase implementation of specific Steps and combinations of Steps may be associated with increased duration of breastfeeding.

Data Resource Profile: Pathways to Health and Social Equity for Children (PATHS Equity for Children)

The PATHS Data Resource is a unique database comprising data that follow individuals from the prenatal period to adulthood. The PATHS Resource was developed for conducting longitudinal epidemiological research into child health and health equity. It contains individual-level data on health, socioeconomic status, social services and education. Individuals’ data are linkable across these domains, allowing researchers to follow children through childhood and across a variety of sectors. PATHS includes nearly all individuals that were born between 1984 and 2012 and registered with Manitoba’s universal health insurance programme at some point during childhood. All PATHS data are anonymized. Key concepts, definitions and algorithms necessary to work with the PATHS Resource are freely accessible online and an interactive forum is available to new researchers working with these data. The PATHS Resource is one of the richest and most complete databases assembled for conducting longitudinal epidemiological research, incorporating many variables that address the social determinants of health and health equity. Interested researchers are encouraged to contact [mchp_access@cpe.umanitoba.ca] to obtain access to PATHS to use in their own programmes of research.

The Effect of Neighborhood Socioeconomic Status on Education and Health Outcomes for Children Living in Social Housing

OBJECTIVES We explored differences in health and education outcomes between children living in social housing and not, and effects of social housings neighborhood socioeconomic status. METHODS In this cohort study, we used the population-based repository of administrative data at the Manitoba Centre for Health Policy. We included children aged 0 to 19 years in Winnipeg, Manitoba, in fiscal years 2006-2007 to 2008-2009 (n = 13,238 social housing; n = 174,017 others). We examined 5 outcomes: age-2 complete immunization, a school-readiness measure, adolescent pregnancy (ages 15-19 years), grade-9 completion, and high-school completion. Logistic regression and generalized estimating equation modeling generated rates. We derived neighborhood income quintiles (Q1 lowest, Q5 highest) from average household income census data. RESULTS Children in social housing fared worse than comparative children within each neighborhood income quintile. When we compared children in social housing by quintile, preschool indicators (immunization and school readiness) were similar, but adolescent outcomes (grade-9 and high-school completion, adolescent pregnancy) were better in Q3 to Q5. CONCLUSIONS Children in social housing had poorer health and education outcomes than all others, but living in social housing in wealthier areas was associated with better adolescent outcomes.

Implementing the Ten Steps for Successful Breastfeeding in Hospitals Serving Low-Wealth Patients

OBJECTIVES The Ten Steps to Successful Breastfeeding is a proven approach to support breastfeeding in maternity settings; however, scant literature exists on the relative impact and interpretation of each step on breastfeeding. We assessed the Ten Steps and their relationship with in-hospital breastfeeding rates at facilities serving low-wealth populations and explored the outcomes to identify step-specific actions. METHODS We present descriptive and nonparametric comparisons and qualitative findings to examine the relationship between the Ten Steps and breastfeeding rates from each hospital using baseline data collection. RESULTS Some steps (1--policy, 2--training, 4--skin-to-skin, 6--no supplements, and 9--no artificial nipples, followed by 3--prenatal counseling, 7--rooming-in) reflected differences in relative baseline breastfeeding rates between settings. Key informant interviews revealed misunderstanding of some steps. CONCLUSIONS Self-appraisal may be less valid when not all elements of the criteria for evaluating Step implementation may be fully understood. Limited exposure and understanding may lead to self-appraisal errors, resulting in scores that are not reflective of actual practices. Nonetheless, the indication that breastfeeding rates may be better mirrored by a defined subset of steps may provide some constructive insight toward prioritizing implementation activities and simplifying assessment. These issues will be further explored in the next phase of this study.

Unconditional Prenatal Income Supplement and Birth Outcomes.

BACKGROUND AND OBJECTIVES: Perinatal outcomes have improved in developed countries but remain poor for disadvantaged populations. We examined whether an unconditional income supplement to low-income pregnant women was associated with improved birth outcomes. METHODS: This study included all mother–newborn pairs (2003–2010) in Manitoba, Canada, where the mother received prenatal social assistance, the infant was born in the hospital, and the pair had a risk screen (N = 14 591). Low-income women who received the income supplement (Healthy Baby Prenatal Benefit [HBPB], n = 10 738) were compared with low-income women who did not receive HBPB (n = 3853) on the following factors: low birth weight, preterm, small and large for gestational age, Apgar score, breastfeeding initiation, neonatal readmission, and newborn hospital length of stay (LOS). Covariates from risk screens were used to develop propensity scores and to balance differences between groups in regression models; γ sensitivity analyses were conducted to assess sensitivity to unmeasured confounding. Population-attributable and preventable fractions were calculated. RESULTS: HBPB was associated with reductions in low birth weight (aRR, 0.71 [95% CI, 0.63–0.81]), preterm births (aRR, 0.76 [95% CI, 0.69–0.84]) and small for gestational age births (aRR, 0.90 [95% CI, 0.81–0.99]) and increases in breastfeeding (aRR, 1.06 [95% CI, 1.03–1.09]) and large for gestational age births (aRR, 1.13 [95% CI, 1.05–1.23]). For vaginal births, HBPB was associated with shortened LOS (weighted mean, 2.86; P < .0001). Results for breastfeeding, low birth weight, preterm birth, and LOS were robust to unmeasured confounding. Reductions of 21% (95% CI, 13.6–28.3) for low birth weight births and 17.5% (95% CI, 11.2–23.8) for preterm births were associated with HBPB. CONCLUSIONS: Receipt of an unconditional prenatal income supplement was associated with positive outcomes. Placing conditions on income supplements may not be necessary to promote prenatal and perinatal health.

Have We Left Some Behind? Trends in Socio-Economic Inequalities in Breastfeeding Initiation: A Population-Based Epidemiological Surveillance Study

OBJECTIVES: Breastfeeding is associated with improved health. Surveillance data show that breastfeeding initiation rates have increased; however, limited work has examined trends in socio-economic inequalities in initiation. The study’s research question was whether socio-economic inequalities in breastfeeding initiation have changed over the past 20 years.METHODS: This population-based study is a project within PATHS Equity for Children. Analyses used hospital discharge data for Manitoba mother–infant dyads with live births, 1988-2011 (n=316,027). Income quintiles were created, each with ≈20% of dyads. Three-year, overall and by-quintile breastfeeding initiation rates were estimated for Manitoba and two hospitals. Age-adjusted rates were estimated for Manitoba. Rates were modelled using generalized linear models. Three measures, rate ratios (RRs), rate differences (RDs) and concentration indices, assessed inequality at each time point. We also compared concentration indices with Gini coefficients to assess breastfeeding inequality vis-à-vis income inequality. Trend analyses tested for changes over time.RESULTS: Manitoba and Hospital A initiation rates increased; Hospital B rates did not change. Significant inequalities existed in nearly every period, across all three measures: RRs, RDs and concentration indices. RRs and concentration indices suggested little to no change in inequality from 1988 to 2011. RDs for Manitoba (comparing initiation in the highest to lowest income quintiles) did not change significantly over time. RDs decreased for Hospital A, suggesting decreasing socio-economic inequalities in breastfeeding; RDs increased for Hospital B. Income inequality increased significantly in Manitoba during the study period.CONCLUSIONS: Overall breastfeeding initiation rates can improve while inequality persists or worsens.RésuméOBJECTIFS : L’allaitement est associé à une meilleure santé. Selon les données de surveillance, les taux d’initiation de l’allaitement maternel augmentent, mais peu d’études examinent les tendances des inégalités socioéconomiques dans l’initiation de l’allaitement. Notre question de recherche était de savoir si les inégalités socioéconomiques dans l’initiation de l’allaitement maternel ont changé au cours des 20 dernières années.MÉTHODE : Cette étude populationnelle s’inscrit dans le programme PATHS Equity for Children. Nos analyses ont utilisé les données de sortie d’hôpital du Manitoba pour les dyades mère-nourrisson avec naissances vivantes de 1988 à 2011 (n=316 027). Des quintiles de revenu ont été créés, contenant chacun ≈20 % des dyades. Les taux d’initiation de l’allaitement maternel sur trois ans, globaux et par quintile, ont été estimés pour l’ensemble du Manitoba et pour deux hôpitaux. Des taux ajustés selon l’âge ont été estimés pour le Manitoba. Les taux ont été modélisés à l’aide de modèles linéaires généralisés. Trois indicateurs, les ratios des taux (RT), les différences de taux (DT) et les indices de concentration, ont permis d’évaluer l’inégalité à chaque point dans le temps. Nous avons aussi comparé les indices de concentration aux coefficients de Gini pour évaluer l’inégalité dans l’allaitement par rapport à l’inégalité des revenus. Des analyses des tendances ont servi à déceler les changements au fil du temps.RÉSULTATS : Les taux d’initiation du Manitoba et de l’hôpital A ont augmenté; les taux de l’hôpital B n’ont pas changé. Des inégalités significatives étaient présentes dans pratiquement toutes les périodes et pour les trois indicateurs: RT, DT et indices de concentration. Les RT et les indices de concentration ont fait état de changements faibles ou nuls dans l’inégalité de 1988 à 2011. Les DT pour le Manitoba (comparant l’initiation du quintile de revenu supérieur au quintile inférieur) n’ont pas significativement changé au fil du temps. Les DT ont diminué pour l’hôpital A, ce qui pourrait signaler une baisse des inégalités socioéconomiques dans l’allaitement; les DT ont augmenté pour l’hôpital B. L’inégalité des revenus a significativement augmenté au Manitoba sur la période de l’étude.CONCLUSIONS : Les taux d’initiation de l’allaitement maternel peuvent s’améliorer globalement alors que l’inégalité subsiste ou s’aggrave.

Contagion from peer suicidal behavior in a representative sample of American adolescents

BACKGROUND Assortative relating is a proposed explanation for the increased occurrence of suicidal behavior among those exposed to suicidal peers. This explanation proposes that high-risk individuals associate with each other, and shared risk factors explain the effect. METHODS Data were obtained from the ADDhealth longitudinal survey waves I and II (n=4834 school attending adolescents). People who reported peer suicidal behavior in the first wave were identified and classified as the exposure group. Potentially confounding variables were identified, and propensity scores were calculated for the exposure variable using logistic regression. Inverse-probability-of-treatment weighted regression estimated the effect of exposure on the risk for a suicide attempt during the first two waves. RESULTS Weighted analysis showed that the group exposed to a friends suicide attempt had a higher occurrence of suicide attempts in both waves. Exposure to peer suicide attempts was associated with increased suicide attempts at baseline (RR=1.93; 95%CI= 1.23-3.04) and 1-year follow-up (RR=1.70; 95%CI= 1.12-2.60). LIMITATION Only two consecutive years of data are provided. Misclassification and recall bias are possible due to the use of self-report. The outcome may be misclassified due to respondent misunderstanding of what constitutes a suicide attempts, versus non-suicidal self-injury. Non-response and trimming reduced the sample size significantly. CONCLUSIONS Assortative relating did not account for all the variance and is currently not sufficient to explain the increased risk after exposure to peer suicidal behavior. Clinicians should assess for exposure to suicidal behaviors in their patients.

Long-Term Benefits of Full-Day Kindergarten: A Longitudinal Population-Based Study

In the first longitudinal, population-based study of full-day kindergarten (FDK) outcomes beyond primary school in Canada, we used linked administrative data to follow 15 kindergarten cohorts (n ranging from 112 to 736) up to grade 9. Provincial assessments conducted in grades 3, 7, and 8 and course marks and credits earned in grade 9 were compared between FDK and half-day kindergarten (HDK) students in both targeted and universal FDK programmes. Propensity score matched cohort and stepped-wedge designs allowed for stronger causal inferences than previous research on FDK. We found limited long-term benefits of FDK, specific to the type of programme, outcomes examined, and subpopulations. FDK programmes targeted at low-income areas showed long-term improvements in numeracy for lower income girls. Our results suggest that expectations for wide-ranging long-term academic benefits of FDK are unwarranted.

Implementing the Ten Steps to Successful Breastfeeding in Multiple Hospitals Serving Low-Wealth Patients in the US: Innovative Research Design and Baseline Findings

BackgroundThe Ten Steps to Successful Breastfeeding are maternity practices proven to support successful achievement of exclusive breastfeeding. They also are the basis for the WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI). This study explores implementation of these steps in hospitals that serve predominantly low wealth populations.MethodsA quasi-experimental design with mixed methods for data collection and analysis was included within an intervention project. We compared the impact of a modified Ten Steps implementation approach to a control group. The intervention was carried out in hospitals where: 1) BFHI designation was not necessarily under consideration, and 2) the majority of the patient population was low wealth, i.e., eligible for Medicaid. Hospitals in the research aspect of this project were systematically assigned to one of two groups: Initial Intervention or Initial Control/Later Intervention. This paper includes analyses from the baseline data collection, which consisted of an eSurvey (i.e., Carolina B-KAP), Maternity Practices in Infant Nutrition and Care survey tool (mPINC), the BFHI Self-Appraisal, key informant interviews, breastfeeding data, and formatted feedback discussion.ResultsComparability was ensured by statistical and non-parametric tests of baseline characteristics of the two groups. Additional findings of interest included: 1) a universal lack of consistent breastfeeding records and statistics for regular monitoring/review, 2) widespread misinterpretation of associated terminology, 3) health care providers’ reported practices not necessarily reflective of their knowledge and attitudes, and 4) specific steps were found to be associated with hospital breastfeeding rates. A comprehensive set of facilitators and obstacles to initiation of the Ten Steps emerged, and hospital-specific practice change challenges were identified.DiscussionThis is one of the first studies to examine introduction of the Ten Steps in multiple hospitals with a control group and in hospitals that were not necessarily interested in BFHI designation, where the population served is predominantly low wealth, and with the use of a mixed methods approach. Limitations including numbers of hospitals and inability to adhere to all elements of the design are discussed.ConclusionsFor improvements in quality of care for breastfeeding dyads, innovative and site-specific intervention modification must be considered.

Maternal health and social outcomes after having a child taken into care: population-based longitudinal cohort study using linkable administrative data

Background We investigated whether mothers experience changes to their health and social situation after having a child taken into care by child protection services, then compared these outcomes with those found in mothers whose children were not taken into care. Methods The cohort includes mothers whose first child was born in Manitoba between 1 April 1998 and 31 March 2011. Mothers whose children were taken into care after age 2 (n=1591) were compared with a matched group of women whose children were not taken into care (n=1591). Results The rates of mental illness diagnoses, treatment use and social factors were significantly higher for mother whose children were taken into care, both in the 2 years before and in the 2 years after the index date. These adjusted relative rates (ARRs) increased significantly for anxiety (before ARR=2.71, after ARR=3.55), substance use disorder (3.77–5.95), physician visits for mental illness (2.83–3.66), number of prescriptions (psychotropic: 4.35–5.86; overall: 2.34–2.94), number of different prescriptions (psychotropic: 2.70-3.27; overall: 1.62–1.70), residential mobility (1.40–1.63) and welfare use (2.07–2.30). Conclusion The health and social situation of mothers involved with child protection services deteriorates after their child is taken into care. Mothers would benefit from supports during this time period to ensure that the outcomes they experience after the loss of their child do not become another barrier to reunification.