Suzanne Tough

Prenatal and Postpartum Maternal Psychological Distress and Infant Development: A Systematic Review

Infant development plays a foundational role in optimal child development and health. Some studies have demonstrated an association between maternal psychological distress and infant outcomes, although the main emphasis has been on postpartum depression and infant-maternal attachment. Prevention and early intervention strategies would benefit from an understanding of the influence of both prenatal and postpartum maternal distress on a broader spectrum of infant developmental outcomes. We conducted a systematic review of studies assessing the effect of prenatal and postpartum maternal psychological distress on five aspects of infant development: global; cognitive; behavioral; socio-emotional; and psychomotor. These findings suggest that prenatal distress can have an adverse effect on cognitive, behavioral, and psychomotor development, and that postpartum distress contributes to cognitive and socio-emotional development.

Factors Influencing Childbearing Decisions and Knowledge of Perinatal Risks among Canadian Men and Women

Background: Women age 35 and older account for an increasing proportion of births and are at increased risk of having difficulties conceiving and of delivering a multiple birth, low birth weight infant, and/or preterm infant. Little is known about men’s and women’s understanding of the maternal age related risks to pregnancy.Objectives: 1) To determine the factors influencing the timing of childbearing for non-parenting men and women, 2) to determine knowledge among non-parenting men and women about maternal age-related reproductive risks, the consequences of low birth weight and multiple birth, and issues related to infertility, and 3) to determine characteristics associated with limited knowledge of these reproductive risks.Methods: An age-stratified random sample of individuals, aged 20–45 years and without children, completed a computer-assisted telephone interview from two urban regions of Alberta, Canada (1006 women and 500 men).Results: Factors that influenced timing of childbearing for both men and women included: financial security (85.8%) and partner suitability to parent (80.2%). Over 70% of men and women recognized the direct relationship between older maternal age and conception difficulties. Less than half knew that advanced maternal age increased the risk of stillbirth, caesarean delivery, multiple birth and preterm delivery.Conclusions: Poor understanding of the links between childbearing after age 35, pregnancy complications and increased risk of adverse infant outcomes limits adults’ ability to make informed decisions about timing of childbearing.

Delayed Child-Bearing

OBJECTIVE To provide an overview of delayed child-bearing and to describe the implications for women and health care providers. OPTIONS Delayed child-bearing, which has increased greatly in recent decades, is associated with an increased risk of infertility, pregnancy complications, and adverse pregnancy outcome. This guideline provides information that will optimize the counselling and care of Canadian women with respect to their reproductive choices. OUTCOMES Maternal age is the most important determinant of fertility, and obstetric and perinatal risks increase with maternal age. Many women are unaware of the success rates or limitations of assisted reproductive technology and of the increased medical risks of delayed child-bearing, including multiple births, preterm delivery, stillbirth, and Caesarean section. This guideline provides a framework to address these issues. EVIDENCE Studies published between 2000 and August 2010 were retrieved through searches of PubMed and the Cochrane Library using appropriate key words (delayed child-bearing, deferred pregnancy, maternal age, assisted reproductive technology, infertility, and multiple births) and MeSH terms (maternal age, reproductive behaviour, fertility). The Internet was also searched using similar key words, and national and international medical specialty societies were searched for clinical practice guidelines and position statements. Data were extracted based on the aims, sample, authors, year, and results. VALUES The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). SPONSOR The Society of Obstetricians and Gynaecologists of Canada. RECOMMENDATIONS 1. Women who delay child-bearing are at increased risk of infertility. Prospective parents, especially women, should know that their fecundity and fertility begin to decline significantly after 32 years of age. Prospective parents should know that assisted reproductive technologies cannot guarantee a live birth or completely compensate for age-related decline in fertility. (II-2A) 2. A fertility evaluation should be initiated after 6 months of unprotected intercourse without conception in women 35 to 37 years of age, and earlier in women > 37 years of age. (II-2A) 3. Prospective parents should be informed that semen quality and male fertility deteriorate with advancing age and that the risk of genetic disorders in offspring increases. (II-2A) 4. Women ≥ 35 years of age should be offered screening for fetal aneuploidy and undergo a detailed second trimester ultrasound examination to look for significant fetal birth defects (particularly cardiac defects). (II-1A) 5. Delayed child-bearing is associated with increased obstetrical and perinatal complications. Care providers need to be aware of these complications and adjust obstetrical management protocols to ensure optimal maternal and perinatal outcomes. (II-2A) 6. All adults of reproductive age should be aware of the obstetrical and perinatal risks of advanced maternal age so they can make informed decisions about the timing of child-bearing. (II-2A) 7. Strategies to improve informed decision-making by prospective parents should be designed, implemented, and evaluated. These strategies should provide opportunity for adults to understand the potential medical, social, and economic consequences of child-bearing throughout the reproductive years. (III-B) 8. Barriers to healthy reproduction, including workplace policies, should be reviewed to optimize the likelihood of healthy pregnancies. (III-C).

Estimating the prevalence of infertility in Canada

BACKGROUND Over the past 10 years, there has been a significant increase in the use of assisted reproductive technologies in Canada, however, little is known about the overall prevalence of infertility in the population. The purpose of the present study was to estimate the prevalence of current infertility in Canada according to three definitions of the risk of conception. METHODS Data from the infertility component of the 2009–2010 Canadian Community Health Survey were analyzed for married and common-law couples with a female partner aged 18–44. The three definitions of the risk of conception were derived sequentially starting with birth control use in the previous 12 months, adding reported sexual intercourse in the previous 12 months, then pregnancy intent. Prevalence and odds ratios of current infertility were estimated by selected characteristics. RESULTS Estimates of the prevalence of current infertility ranged from 11.5% (95% CI 10.2, 12.9) to 15.7% (95% CI 14.2, 17.4). Each estimate represented an increase in current infertility prevalence in Canada when compared with previous national estimates. Couples with lower parity (0 or 1 child) had significantly higher odds of experiencing current infertility when the female partner was aged 35–44 years versus 18–34 years. Lower odds of experiencing current infertility were observed for multiparous couples regardless of age group of the female partner, when compared with nulliparous couples. CONCLUSIONS The present study suggests that the prevalence of current infertility has increased since the last time it was measured in Canada, and is associated with the age of the female partner and parity.

Causal assessment of dietary acid load and bone disease: a systematic review & meta-analysis applying Hill's epidemiologic criteria for causality

BackgroundModern diets have been suggested to increase systemic acid load and net acid excretion. In response, alkaline diets and products are marketed to avoid or counteract this acid, help the body regulate its pH to prevent and cure disease. The objective of this systematic review was to evaluate causal relationships between dietary acid load and osteoporosis using Hills criteria.MethodsSystematic review and meta-analysis. We systematically searched published literature for randomized intervention trials, prospective cohort studies, and meta-analyses of the acid-ash or acid-base diet hypothesis with bone-related outcomes, in which the diet acid load was altered, or an alkaline diet or alkaline salts were provided, to healthy human adults. Cellular mechanism studies were also systematically examined.ResultsFifty-five of 238 studies met the inclusion criteria: 22 randomized interventions, 2 meta-analyses, and 11 prospective observational studies of bone health outcomes including: urine calcium excretion, calcium balance or retention, changes of bone mineral density, or fractures, among healthy adults in which acid and/or alkaline intakes were manipulated or observed through foods or supplements; and 19 in vitro cell studies which examined the hypothesized mechanism. Urine calcium excretion rates were consistent with osteoporosis development; however calcium balance studies did not demonstrate loss of whole body calcium with higher net acid excretion. Several weaknesses regarding the acid-ash hypothesis were uncovered: No intervention studies provided direct evidence of osteoporosis progression (fragility fractures, or bone strength as measured using biopsy). The supporting prospective cohort studies were not controlled regarding important osteoporosis risk factors including: weight loss during follow-up, family history of osteoporosis, baseline bone mineral density, and estrogen status. No study revealed a biologic mechanism functioning at physiological pH. Finally, randomized studies did not provide evidence for an adverse role of phosphate, milk, and grain foods in osteoporosis.ConclusionsA causal association between dietary acid load and osteoporotic bone disease is not supported by evidence and there is no evidence that an alkaline diet is protective of bone health.

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.

Sudden Death from Asthma in 108 Children and Young Adults

To identify factors that may contribute to asthma mortality, 108 acute asthma deaths were reviewed. Information was obtained from medical records, next-of-kin, and autopsy records. The fatal asthmatic was characterized by early-onset asthma, severe disease requiring systemic corticosteroids, and prior hospitalization. Risk factors associated with gender, season, employment, and region were also identified. The fatal attack was characterized by an identifiable trigger, delay in seeking medical attention, and rapid deterioration in clinical status. Death due to asthma was confirmed in 95% of autopsied cases. Adrenal cortical abnormalities were recorded for 18.7% of cases. We conclude that, in addition to established risk factors, complications associated with the use of systemic steroids may contribute to the risk for sudden death in this age group.

Advanced maternal age and risk perception: A qualitative study

BackgroundAdvanced maternal age (AMA) is associated with several adverse pregnancy outcomes, hence these pregnancies are considered to be “high risk.” A review of the empirical literature suggests that it is not clear how women of AMA evaluate their pregnancy risk. This study aimed to address this gap by exploring the risk perception of pregnant women of AMA.MethodsA qualitative descriptive study was undertaken to obtain a rich and detailed source of explanatory data regarding perceived pregnancy risk of 15 women of AMA. The sample was recruited from a variety of settings in Winnipeg, Canada. In-depth interviews were conducted with nulliparous women aged 35 years or older, in their third trimester, and with singleton pregnancies. Interviews were recorded and transcribed verbatim, and content analysis was used to identify themes and categories.ResultsFour main themes emerged: definition of pregnancy risk, factors influencing risk perception, risk alleviation strategies, and risk communication with health professionals.ConclusionsSeveral factors may influence womens perception of pregnancy risk including medical risk, psychological elements, characteristics of the risk, stage of pregnancy, and health care provider’s opinion. Understanding these influential factors may help health professionals who care for pregnant women of AMA to gain insight into their perspectives on pregnancy risk and improve the effectiveness of risk communication strategies with this group.

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.

Validation of Canadian mothers' recall of events in labour and delivery with electronic health records

BackgroundMaternal report of events that occur during labour and delivery are used extensively in epidemiological research; however, the validity of these data are rarely confirmed. This study aimed to validate maternal self-report of events that occurred in labour and delivery with data found in electronic health records in a Canadian setting.MethodsData from the All Our Babies study, a prospective community-based cohort of women’s experiences during pregnancy, were linked to electronic health records to assess the validity of maternal recall at four months post-partum of events that occurred during labour and delivery. Sensitivity, specificity and kappa scores were calculated. Results were stratified by maternal age, gravidity and educational attainment.ResultsMaternal recall at four months post-partum was excellent for infant characteristics (gender, birth weight, gestational age, multiple births) and variables related to labour and delivery (mode of delivery, epidural, labour induction) (sensitivity and specificity >85%). Women who had completed a university degree had significantly better recall of labour induction and use of an epidural.ConclusionMaternal recall of infant characteristics and events that occurred during labour and delivery is excellent at four months post-partum and is a valid source of information for research purposes.