Comparison of midwifery, family medicine, and obstetric patients' understanding of weight gain during pregnancy: a minority of women report correct counselling.
We hypothesized that differences in models of care between health care providers would result in variations in patients' reports of counselling. Our objective was to compare what women reported being advised about weight gain during pregnancy and the risks of inappropriate weight gain according to their type of health care provider.
A cross-sectional survey was conducted using a self-administered questionnaire at obstetric, midwifery, and family medicine clinics in Hamilton, Ontario. Women were eligible to participate if they had had at least one prenatal visit, could read English, and had a live, singleton pregnancy.
Three hundred and eight women completed the survey, a 93% response rate. Care for 90% of the group was divided approximately evenly between midwives, family physicians, and obstetricians. A minority of women looked after by any of the types of care providers reported being counselled correctly about how much weight to gain during pregnancy (16.3%, 10.3%, 9.2%, and 5.7% of patients of midwives, family physicians, obstetricians, or other types of care providers, respectively, P = 0.349). A minority of women with any category of care provider was planning to gain an amount of weight that fell within the guidelines or reported being told that there were risks to themselves or their babies with inappropriate gain.
In this study comparing reported counselling between patients of obstetricians, midwives, family physicians, and other health care providers, low rates of counselling about gestational weight gain were universally reported. There is a common need for more effective counselling.
Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, McMaster Universityand Hamilton Health Sciences, Hamilton, Ontario, Canada. mcdonals@mcmaster.ca
The purpose of this study was to identify reproductive risk factors associated with dysglycemia (diabetes, impaired glucose tolerance, and impaired fasting glucose) in a contemporary multiethnic population.
We studied 14,661 women screened with an oral glucose tolerance test for the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) trial. Reproductive risk factors were compared in normoglycemic and dysglycemic women.
Dysglycemia was significantly associated with the number of children born (odds ratio 1.03 per child [95% CI 1.01-1.05]), age (1.05 per year [1.04-1.05]), non-European ancestry (1.09 [1.01-1.17]), preeclampsia/eclampsia (1.14 [1.02-1.27]), irregular periods (1.21 [1.07-1.36]), and gestational diabetes mellitus (GDM) (1.53 [1.35-1.74]). The relationship between GDM and dysglycemia did not differ across BMI tertiles (P = 0.84) nor did the relationships of other risk factors.
Reproductive factors, particularly GDM, are associated with dysglycemia in middle-aged women from many ethnicities. Reproductive factors can be used to counsel young women about their future risk of dysglycemia, whereas in middle age they may help screen for dysglycemia.
To determine the self-reported counselling practices of health care providers with regard to prenatal weight gain and the risks of inappropriate gain.
We conducted a cross-sectional survey using a self-administered questionnaire at obstetrician, midwifery, and family medicine clinics in Hamilton, Ontario. Health care providers were eligible to participate if they provided prenatal care and could read English sufficiently well to complete the survey.
Forty-two health care providers completed the survey; of these, 95% reported counselling women to gain a specific amount of weight, and 81% reported that they recommended values that were in accordance with the 2009 Institute of Medicine/Health Canada guidelines. The risks of excess and inadequate gain were reported as being discussed with their patients by 87% and 76% of health care providers, respectively.
In this first study to the best of our knowledge of gestational weight gain counselling since the publication of the 2009 guidelines, most health care providers reported discussing weight gain and the risks of inappropriate gain, which is incongruent with previously published information on their patients' reports of counselling.
Because breastfeeding is the optimal form of infant feeding, this study was conducted to determine the effect of gestational age on breastfeeding in term infants.
A retrospective population-based cohort study of singleton/twin hospital births was conducted in Ontario, Canada between April 1, 2009, and March 31, 2010. Multivariate logistic regression was used to determine the adjusted effect of gestational age on breastfeeding.
Our study population comprised 92,364 infants, of whom 80,297 (86.9%) were exclusively or partially breastfed at the time of hospital discharge. Multivariate logistic regression analyses demonstrated that early-term infants had lower odds of being breastfed compared with infants born at 41 weeks gestation (40 weeks: aOR, 0.93; 95% CI, 0.86-0.99; 39 weeks: aOR, 0.87; 95% CI, 0.81-0.93; 38 weeks: aOR, 0.81; 95% CI, 0.75-0.88; 37 weeks: aOR, 0.74; 95% CI, 0.67-0.82).
Using a population-based approach, we found that infants born at 40, 39, 38, and 37 weeks gestation had increasingly lower odds of being breastfed compared with infants born at 41 weeks. Clinicians need to be made aware of the differences in outcomes of infants delivered at early and late term, so that appropriate breastfeeding support can be provided to women at risk for not breastfeeding.
To estimate the population-based prevalence and predictors of exclusive breastfeeding at hospital discharge in singleton and twin term newborns.
We studied all hospital births in the province of Ontario, Canada, between April 1, 2009, and March 31, 2010, to perform a retrospective cohort study. We included live singleton and twin births, at term (37 0/7 weeks of gestation to 41 6/7 weeks of gestation), with information about feeding at maternal-newborn discharge. Descriptive statistics were performed and logistic regression was used to identify factors related to exclusive breastfeeding.
Our study population consisted of 92,364 newborns, of whom 56,865 (61.6%) were exclusively breastfed at discharge. Older, nonsmoking, higher-income mothers with no pregnancy complications or reproductive assistance were more likely to breastfeed. Mothers of twins were less likely to exclusively breastfeed (adjusted odds ratio [OR] 0.30, 95% confidence interval [CI] 0.25-0.36) as were women who did not attend prenatal classes (adjusted OR 0.80, 95% CI 0.76-0.83). Compared with patients of obstetricians (57%), women cared for by midwives (87%, adjusted OR 4.49, 95% CI 4.16-4.85) and family physicians (67%, adjusted OR 1.54, 95% CI 1.47-1.61) were more likely to exclusively breastfeed. Breastfeeding after a planned (50%, adjusted OR 0.56, 95% CI 0.52-0.60) or unplanned (48%, adjusted OR 0.48, 95% CI 0.44-0.51) cesarean delivery was less common than after a spontaneous vaginal birth (68%). Neonates born at 39, 38, and 37 weeks of gestation (compared with 41 weeks of gestation) were increasingly less likely to breastfeed (adjusted ORs 0.93, 95% CI 0.89-0.98; 0.84, 95% CI 0.80-0.88; and 0.71, 95% CI 0.67-0.76).
This large population-based study found that fewer than two thirds of term newborns are exclusively breastfed at hospital discharge, substantially lower than previously reported.
The extent to which temporal increases in the use of prenatal ultrasonography reflect changes in maternal risk is unknown. In this population-based study, we examined the use of prenatal ultrasonography from 1996 to 2006 in Ontario.
With fiscal year 1996/97 as the baseline, we evaluated the relative risk (RR) and 95% confidence interval (CI) for the change in rates of ultrasonography for each subsequent year. The RR was adjusted for maternal age, income, rural residence, maternal comorbidities, receipt of genetics consultation or amniocentesis--all in the index pregnancy--and history of complications in a prior pregnancy.
The study sample consisted of 1 399 389 singleton deliveries. The rate of prenatal ultrasonography increased from 2055 per 1000 pregnancies in 1996 to 3264 per 1000 in 2006 (adjusted RR 1.55, 95% CI 1.54-1.55). The rate increased among both women with low-risk pregnancies (adjusted RR 1.54, 95% CI 1.53-1.55) and those with high-risk pregnancies (adjusted RR 1.55, 95% CI 1.54-1.57). The proportion of pregnancies with at least four ultrasound examinations in the second or third trimesters rose from 6.4% in 1996 to 18.7% in 2006 (adjusted RR 2.68, 95% CI 2.61-2.74). Paradoxically, this increase was more pronounced among low-risk pregnancies (adjusted RR 2.92, 95% CI 2.83-3.01) than among high-risk pregnancies (adjusted RR 2.25, 95% CI 2.16-2.35).
Substantial increases in the use of prenatal ultrasonography over the past decade do not appear to reflect changes in maternal risk. Nearly one in five women now undergo four or more ultrasound examinations during the second and third trimesters. Efforts to promote more appropriate use of prenatal ultrasonography for singleton pregnancies appear warranted.
Notes
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Randomized controlled trials have demonstrated that periconceptional folic acid supplementation has a dramatic effect in reducing neural tube defects, one of the most serious congenital anomalies. Unfortunately, supplementation tends to be suboptimal in disadvantaged populations.
The primary objective was to determine patient factors associated with a lack of use of periconceptional folic acid among Canadian women in a multi-ethnic, urban setting. Our secondary objective was to assess patient knowledge about folic acid tablet supplementation and its link to reduced birth defects.
We undertook a cross-sectional study to survey postpartum Toronto women on their use and knowledge of periconceptional folic acid.
Of the 383 women surveyed, only 28% took folic acid or a multivitamin containing folic acid during the periconceptional period. Multivariate analysis revealed that the use of periconceptional folic acid was more common among women of Jewish descent (adjusted relative risk [RR] 0.3; 95% confidence interval [CI], 0.04-0.9) and those who had 1 or no children (adjusted RR 0.6; 95% CI, 0.4-0.8). Not taking folic acid was associated with unplanned pregnancy (adjusted RR 1.5; 95% CI, 1.4-1.6) and a lack of knowledge about when folic acid should be taken (adjusted RR 1.8; 95% CI, 1.6-1.8).
Ethnic background is an independent predictor of periconceptional folic acid use.
