healthy mothers and healthy babies - perinatalservicesbc...aga khan university, department of...

February 21 - 22, 2014 | Vancouver, BC

Healthy Mothersand Healthy Babies: New Research and Best Practice Conference

S Y L L A B U S

Author name(s) and organization name(s): MiGHT -‐ Maternal Infant Global Health Team (Global Collaborators in Research): Premji S (nominated PI), Dahinten S (Co-‐PI), Gulamani S (Co-‐PI), Jehan I (Co-‐PI), Letourneau N (Co-‐PI), Musana J (Co-‐PI), Shaikh S (Co-‐PI), Kanji Z, Mawji A, Naqvi, H, Naugler C, Samia P, Wasim S, Yim, IS. Collaborators: Amunga DA, Asami D, Ghani F, King A, Mohamed A, Mteri VM, Mwasha L, Okoko CO, Wambua J; Consultant: M Sarah Rose

Organizations: Aga Khan University, School of Nursing and Midwifery, Karachi, Pakistan; Aga Khan University, Department of Community Health Sciences; Aga Khan Hospital, Nairobi, Kenya, Department of Obstetrics and Gynecology and Department of Pediatrics; University of Calgary, Faculty of Nursing, Faculty of Medicine, Alberta Children’s Hospital Research Institute for Child & Maternal Health; University of British Columbia, School of Nursing, Norlien/ACHF Chair in Parent-‐Infant Mental Health, Mount Royal University, School of Nursing and Midwifery; University of California, Irvine, Department of Psychology and Social Behavior. Primary presenters (presenter name, suffix, title, organization name, stress address (work), city, province/state, postal code, telephone numbers, fax number & email address. Dr. Shahirose Premji, Associate Professor, University of Calgary, Faculty of Nursing, 2500 University Drive NW, Calgary, AB, CANADA T2N 1N4; phone: 403-‐220-‐2081; fax: 403-‐284-‐4803; Email: [email protected] Co-‐presenter: Dr. Aliyah Mawji, Assistant Professor, Mount Royal University, School of Nursing, 4825 Mount Royal Gate SW, Calgary, AB, CANADA T3E 6K6; Phone: 403-‐440-‐8631; Email: [email protected] Background/Rationale: Evidence points to perinatal distress (i.e., stress, anxiety, and depression) as an important causative factor for preterm birth. Both preterm birth and perinatal distress are world-‐wide problems, but are especially burdensome in low-‐ and middle-‐income countries (LMIC) and remains an important priority if we are to achieve millennium development goals 4 and 5. Methods: We searched peer-‐reviewed databases (e.g., MEDLINE, EMBASE, and CINHAL), grey literature, and reference lists of pertinent articles. A critical synthesis was undertaken of all articles in the English language, regardless of study design, that examined any determinant of perinatal mental health or examined causal pathways between perinatal distress and maternal and infant health outcomes. Results: LMIC were represented in only 8% and 15% of the pregnant-‐ and post-‐partum related studies, compared to 90% of high income countries and LMIC studies did not focus on prevention of preterm birth. We present a conceptual framework based on the critical synthesis of literature that explicates determinants of perinatal distress and objective indicators of multisystem dysregulation representing pathologic effects of perinatal distress.

Healthy Mothers and Healthy Babies: New Research and Best Practice Conference 105

C O N C U R R E N T S E S S I O N C

C1i Standard Lecture | New Research

Stress-related Pathways to Preterm Birth: ‘10/90’ GapShahirose Premji, Aliyah Mawji

Conclusions: We will provide new direction for research examining causal pathways between perinatal distress and preterm birth. Learning Objectives Participants will (a) develop an understanding of the multidimensional nature of perinatal distress within the context of social, cultural and environmental phenomena of women in Pakistan, Kenya and Tanzania; (b) explore causal pathways between perinatal distress and maternal and infant health outcomes, (c) learn about objective, biochemical measures of perinatal distress as tools to assist in identifying high-‐risk mothers and infants. Summary Annually, fifteen million babies are born prematurely worldwide, and evidence points to perinatal distress (i.e., stress, anxiety, or depression) as causative factor. Both preterm birth and perinatal distress are world-‐wide problems that are especially burdensome in low-‐ and middle-‐income countries. Discover a new conceptual approach to examine causal pathways between perinatal distress and preterm birth. Biography Dr. Premji has 22 years’ experience in newborn health and has practiced clinically or provided technical expertise in countries such as Australia, China, Kenya, Tanzania, Pakistan, India, and Syria. Dr. Mawji has been in academia for 7 years and prior to that she was a community health nurse in global health, working with the Aga Khan Foundation in Geneva. Her teaching and research focuses on community health, with emphasis on maternal child and newborn health.

106 February 21 - 22, 2014 | Vancouver, BC


Background Information Late preterm infants (LPIs) are infants born between 34 0/7 weeks and 36 6/7 weeks gestational age.1,2 LPIs make up about 75% of preterm births.3Alberta’s preterm birth rates are the highest in Canada with hospitals reporting a preterm birth rate of 8.8%.4 In 2012 in Calgary, of the 16,007 total live births, 1088 (6.8%) were LPIs.5 LPIs are a growing proportion of preterm infants and represent a distinct subpopulation of preterm infants due to their unique medical issues. These distinctive medical issues include hypoglycemia due to feeding difficulties, jaundice, respiratory distress syndrome, apnea, bradycardia, increased risk for sepsis, and temperature instability,1,6, 7 and the fact that they are often treated as if they were term infants due to their older gestational age. Significance of the Issue LPIs comprise a growing vulnerable population that is at higher risk of health complications. LPIs are often re-‐admitted to hospitals due to the complexity of their health challenges and this has significant implications for the family and the health care system.1,6, 7 As a result of their unique medical issues, LPIs require specialized care from various health care providers including public health nurses. One of the unique challenges for care of the LPI is that there are limited standards of care for Public Health Nurses (PHNs) to follow about caring for LPIs in the community. Research Questions

1) What are the PHNs’ experiences of caring for LPIs? 2) What challenges do PHNs experience in providing care to LPIs and their families?

Preliminary Analysis This paper reports on the first part of a larger mixed-‐ method study regarding the experiences of PHNs caring for LPIs and their families. This presentation provides a preliminary analysis of what PHNs experience when caring for LPIs in homes and clinics, where they provide nursing support. Learning Objectives of the Presentation Participants attending this presentation will be able to:

1) Describe public health nurses’ experiences in caring for LPIs through an overview of the preliminary analysis of data

2) Recognize the bio-‐psycho and social challenges in providing nursing care to LPIs and their families

3) Examine the challenges of PHNs in providing appropriate short term support to familieswith LPIs



C1ii Standard Lecture | New Research

Improving Community-based Care for Late Pre-term InfantsAliyah Mawji, Genevieve Currie

References

1. Engle, W.A., Tomashek, K. M., Wallman, C., & the Committee on Fetus and Newborn. (2007). “Late-‐preterm” infants: A population at risk. Pediatrics,120(6),1390-‐1401.

2. Whyte, R. K. (2010). Safe discharge of the late preterm infant [position statement FN 2010-‐01]. Paediatrics &Child Health,15(10), 665-‐660.

3. Malley, P. V., Bailey, S., & Hendricks-‐Muñoz, K. D. (2010) Clinical issues in the management of late preterm infants. Current Problems in Pediatric and Adolescent Health Care, 40, 218-‐233. doi:10.1016/j.cppeds.2010.07.005

4. Canadian Institute of Health Informatics. Hospital Care: Updated hospital data. (2011). Retrieved from http://www.cihi.ca/cihi-‐ext-‐portal/internet/en/document/types+of+care/hospital+care/release_12may11

5. Alberta Health Services PHANTIM Database in Calgary.2012. 6. Wang, M. L., Dorer, D. J., Fleming, M. P., & Catlin, E. A. (2004). Clinical outcomes of near-‐term infants. Pediatrics, 114(2),

372-‐376. 7. MacBird, T., Bronstein, J. M., Hall, R. W., Lowery, C., Nugent, R., & Mays, G.P. (2010). Late preterm infants: Birth outcomes

and health care utilization in the first year. Pediatrics, 126(2):e311-‐e319. doi: 10.1542/peds.2009-‐2869

Acknowledgements

This project received funds from the Alberta Centre for Child, Family and Community Research (ACCFCR) for the study entitled, “Caring for Late Preterm Infants: Public Health Nurses’ and Parent’s Experiences”.



14-01-27

1

A relationship for life: Understanding and

Supporting the Attachment Connection

Dr. Vanessa Lapointe, Registered Psychologist Clinic Founder, The Wishing Star Invited Professional Associate, Neufeld Institute

Dr. Vanessa Lapointe, R. Psych, Copyright

Plan

l  Some discussion around current research

l  Presentation of current theory and understanding

l  Bringing relationship to life – ideas on “how to”

l  Learning objectives -‐ Participants will learn about: l  (1) current research in the area of attachment, brain development,

and general outcomes;

l  (2) related theory as applied to the pre-‐ and perinatal period; and l  (3) associated best practices for support that focuses on concrete

application of research and theory.



What does it mean to be held in another’s mind? Why does it matter, and how does such a feeling develop? Everything that we know about [children] leads to the conclusion that they seek human connection, not only to survive but for its own sake. They are born looking for us. Given a choice of what to look at in their first hours, it is always the human face they choose. -Dr. Jeree Paul

What’s all this talk about “relationship”

Defining Attachment


What is attachment?

l  Attachment is the relationship between a key big person and a child

l  Primary attachments are the big people of central importance to a child’s life – typically parents

•  Attachment system is activated in times of stress (upset, hurt, ill) and child then initiates attachment behaviors


Attachment

l  The most significant “environment” of a young child’s life

l  “Coherent interpersonal relationships produce coherent neural integration within the child that is at the root of adaptive self-‐regulation.” (Siegel, 2001, p. 86)

l  In early childhood, positive relationships offer the best environment for optimal brain development (Davies, 2004)



C1iii Standard Lecture | Innovative Practices

A Relationship for Life: Understanding and Supporting the Attachment ConnectionVanessa Lapointe

14-01-27

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What is attachment?

l  Attachment is biological, evolutionary, neurological, and emotional in nature

l  As children we are born to attach – the developmental process constantly drives at this

l  As adults, we are primed to facilitate the attaching of our children – it is part of our wiring


What is attachment?

l  Attachment is the relationship “super glue” that holds a child in close PROXIMITY to a parent/key caregiver

l  Children are meant to PURSUE proximity

l  Adults are meant to PROVIDE proximity l  When proximity is disrupted, a parent is intuitively driven to

restore it


What is attachment?

l  What is attachment? l  Purpose of attachment is to keep the child safe AND make

the child feel safe/secure l  Hierarchy is an essential component of attachment

l  Attachment is as important to healthy child development as eating or sleeping

l  When attachment is compromised, children are affected on a physiological level


What does it all come down to?

1. Brains

2. Relationships

3. Hierarchy


Brains


The brain and experience The brain is organized in a hierarchical fashion – from the bottom up

Neural system change is “use-‐dependent”

The brain develops sequentially

The brain develops most rapidly early in life

Neural systems can change but some are easier to change than others

The human brain is designed for a different world – a more relational world

Dr. Bruce Perry – Applying key principles of neurodevelopment to approaches to intervention



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Brain Development and Caregiving Relationships

l  Human infants are designed to “orient” to caring adults

l  As babies are lovingly cared for, there is created “a set of specific sensory stimuli which are translated into specific neural activations in areas of the developing brain destined to become responsible for socio-‐emotional communication and bonding” (Perry 2002, p. 95)

Relationship


Relationship Dimensions

1. Physical proximity l  Bowlby

2. Emotional proximity l  Tronick


Relationship – The Physical Dimension

Quality of Caregiving l  Loving l  Rejecting l  Inconsistent l  “Atypical”

Type of Attachment l  Secure (55%) l  Avoidant (23%) l  Resistant (8%) l  Disorganized (15%)

Dr. Vanessa Lapointe, R. Psych. 2011

Relationship – The Emotional Dimension

l  Tronick – The Still Face (video clip)


Hierarchy




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Hierarchy as Essential

l  The dance of proximity l  Providers and seekers

l  Provider has their “alpha” role fully engaged

l  Child has dependent instinct fully engaged

l  Promotes softness (no defenses) and paves the way for development to unfold

l  Never ever ever should the hierarchy reverse!


Bringing it altogether Brains, relationship, and hierarchy come together to

profoundly change outcomes for children


The Profound Impact on Outcomes

l  “Most striking … were the contrasts observed between the three FASD groups and Group 4 (the group with no evidence of CNS abnormality). FASD groups characteristics: l  Physical and sexual abuse was 2-‐ to 5-‐fold more prevalent l  2x as likely to be in adoptive care l  Significantly less likely to receive prenatal care.

l  Yet, prenatal exposure to alcohol and other illicit drugs was comparably high across all four groups.”

Making a Difference Nurturing attachment in the parent-‐infant relationship


A Note on Effective Intervention

l  Guarlnick: We need a “second generation” of research that tells us what works, with whom, and at what stages.

l  Bowman (2000): “Early intervention programs appear to be a little like preparing a gourmet meal from an incomplete recipe. We have a general idea of the ingredients but are not sure about how much, in what order, at what temperature and for how long those ingredients should be cooked. Even with a good chef, the meal doesn’t seem to fit all of the diners all the time.”

l  Landy (2001): “Perhaps what we must aim for is the availability of a smorgasbord, deftly adapted to the needs of the families.”

Copyright Dr. Vanessa Lapointe, R. Psych. 2011

Landy 2001

Nurturing attachment

1.  Celebrate intuition

2.  Work from a sensory-‐based place

3.  Build upon the existing strengths

4.  Provide concrete, simple orienting suggestions to parents who are struggling

5.  Build up ‘villages’




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The Nurturer in Us – Intuitive Care


Sensory Based Connections

l  Connection through being with l  Children in the first year of life experience the emotion of

connection primarily through their senses l  Connection is all about the senses – touch, taste, smell, hear,

see l  Children connect through the concretes l  Brains are changed in incredible ways with this input…


Dr. Gordon Neufeld

Strengths-‐based approach

l  Work with a parent to have them notice what is working in the relationship with their child

l  Do this quietly and without parade

l  “oh…look at how he turned his head at the sound of your voice”

l  “it seems her cry is a little less stressed when she is in your arms – she sure knows who is mom/dad”

l  “look how he is always coming back to your face – it is like it is the most important face in the world to him…”


Concrete Orienting Suggestions

l  A Simple Gift Series (IMP)

Simple Gift

l  Voices

l  Aversion to comforting the child

l  Intrusiveness

l  Not “being there” for the child

l  Parentification of child – having child worry about parent

Prepared by Dr. Lapointe, R. Psych.


l  Always comfort a child who is emotionally upset, physically hurt or ill…you cannot spoil a child by comforting in these circumstances. Instead, you help them to learn how to calm themselves down and make them feel safe

l  Caregivers should always respond to a young child’s cries l  Underscore the importance of the first 2 years of life l  Encourage parents to:

l  Cuddle/have close physical contact with child l  Organize their child’s day l  Plan for uninterrupted playtime with their child

l  Encourage parents to watch their child’s face and eyes, try to imagine what they are thinking and feeling…watch, wait, wonder*

Prepared by Dr. Lapointe, R. Psych. *Not the therapy program. Adapted from IMP/Benoit.



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l  Help big people think about the child’s feelings l  How does your baby/child “talk” to you? l  How does your child/baby tell you he needs your help? l  What makes your baby/child upset?

l  When your baby/child is crying, what is she thinking/feeling?

Prepared by Dr. Lapointe, R. Psych.

It takes a village

l  Look for outside sources of support

l  Family, friends, community, baby groups, etc.

l  Parents were never meant to go this alone!



“When a child is held in mind, the child feels it, and knows it. There is a sense of safety, of

containment, and most important, existence in that other, which is vital. ... It seems to me that one

of life’s greatest privileges is just that -‐ the experience of

being held in someone’s mind.”

-Dr. Jeree Paul

Resources

l  www.gordonneufeld.com

l  www.sickkids.ca/imp l  Simple Gift series

l  www.odinbooks.ca

l  www.childtrauma.org


References l  Astley, S. J. (2010). Profile of the first 1400 patients receiving diagnostic evaluations for

fetal alcohol sprectrum disorder at the Washington State Fetal Alcohol Syndrome Diagnostic & Prevention Network. Canadian Journal of Clinical Pharmacology, 17 (1), Winter 2010:e132-‐e164.

l  Bowman, T. G. (2000). Home visiting for infants and their familes. In Newsletter of the Infant Mental Health Promotion Project (IMP) Volume 29, Winter 2000-‐2001.

l  Guralnick, M. J. (1997). Second-‐generation research in the field of early intervention. In M. J. Guarlnick (Ed.), The Effectiveness of Early Intervention (pp. 3–20). Baltimore, MD: Paul H. Brookes Publishing.

l  Landy, S., (2001). Fulfilling the promise of early intervention. In Newsletter of the Infant Mental Health Promotion Project (IMP), Volume 32, Winter 2001-‐02.

l  Paul, J. (2006). Being Held in Another’s Mind. In Concepts for Care: 20 essays on infant-‐toddler development and learning, Eds. Lally, J., Mangione, P.L., & Greenwald, D.

l  Perry, B. D. (2006). Applying Principles of neurodevelopment to clinical work with maltreated and traumatized children. In Working with Traumatized Youth in Child Welfare, Ed. Boyd Webb, N.

l  Perry, B.D. (2002) Childhood experience and the expression of genetic potential: what childhood neglect tells us about nature and nurture Brain and Mind 3: 79-‐100.

Dr. Vanessa Lapointe, R. Psych & Associates

778-294-8732

www.lapointepsychology.com

South Surrey, BC

Encouraging hope through nurturing support, counselling, assessment,

consultation, and training.


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14-01-27

1

Comparing CenteringPregnancy to Standard Prenatal Care plus Prenatal Education

Suzanne Tough, PhD, Ingunn Benediktsson, BHSc

Learning Objectives Ø To understand the design of the CenteringPregnancy program and its implementation in Calgary, Alberta

Ø To understand the characteristics of women entering CenteringPregnancy compared to traditional prenatal education in this area

Ø To understand the relative changes in psychosocial health among CenteringPregnancy participants after completion of the program

CenteringPregnancy in Calgary

What We Knew Ø Some women need more support

§  Young maternal age (<25 yrs)

§  Low income (<$40,000/yr)

§  Non-‐Caucasian

§  Lower social support

§  History of abuse

CenteringPregnancy

Ø Especially among vulnerable populations, research reports: §  lower rates of preterm delivery §  improved psychosocial outcomes §  improved satisfaction with care §  improved prenatal knowledge §  greater readiness for both delivery and baby care

§  higher rates of breastfeeding

Who We Are

CenteringPregnancy Group Prenatal Care

N ~130

Prediction of Preterm Birth Bio-‐markers of Preterm Birth

N ~1,800

AOB Cohort Prenatal Care & Women’s Well-‐Being

N ~3,300



C2i Standard Lecture | Innovative Practices

Comparing CenteringPregnancy® to Standard Prenatal Care plus Prenatal EducationSuzanne Tough, Ingunn Benediktsson

14-01-27

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Ø Group of 8 to 12 women §  Similar due dates

Ø Ten 2-‐hour group sessions §  Assessment, education, and support §  Co-‐facilitated: physician & prenatal educator

Group Prenatal Care in Calgary

Ø Engagement of AHS

Ø Engagement of physicians and educators

Ø Training and purchase of materials

Ø Recruitment and patience

Steps to Implementation

From the Women

“Everything I needed was right there.”

27-‐year-‐old first-‐/me mom

Women are ge4ng more than they realized they

needed

From the Women “I tell everyone I’ve never had this much support and it really helped...it’s the first <me I didn’t get postpartum depression.”

38-‐year-‐old mother with other children


needed

From the Physicians “It feels like we’re able to provide a much richer quality

of care to the pa<ents”

Physicians are involved in

providing richer care

From the Physicians

“When you have a beBer rela<onship, you feel like you’re providing beBer

care” Physicians are involved in




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From the Educators

“Trying to be part of

something new and

innova<ve for our area that

would possibly benefit the

women that we deal with”

Educators are invested in success

From the Educators

“I want to give...a founda<on

for them to have a successful

birth experience, a successful

paren<ng experience.”


The Experiences


Physicians are involved in



needed

CenteringPregnancy vs. Prenatal Education

Research Program

Ø Quantitative Research Question §  Compared to individual prenatal care, does group prenatal care improve: •  social support and mental health outcomes? •  infant birth outcomes?

Survey Timeline

Birth

Survey @ <20 weeks

Survey @ 32-‐36 wks

Survey @ 4 months

150 women

141 women

134 women

89% Response

Rate

CenteringPregnancy Par<cipa<on



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What We Asked Birth

Prenatal Health

Emo<onal/Physical Health

Social Support

Service U<liza<on

Pregnancy History

Demographics

Exercise and Food

Life Events

Birth Outcomes

Breas\eeding

Lifestyle

Paren<ng

Child Development

5 yrs

Comparing Prenatal Education

Standard prenatal care + prenatal educa/on and

Group prenatal

care

106 participants

(excluding women in CenteringPregnancy

and prenatal education)

619 participants

(including women declaring supplementary participation

an additional prenatal education class)

Comparing Prenatal Education

16% 14%

39%

25%

13%

26%

5% 5%

21%

9% 5%

10%

High School or Less

Income <$40,000

Non-‐Caucasian Language other than

English

Food Insecurity

First Prenatal Care at Walk-‐

in Clinic

CenteringPregnancy Prenatal Educa<on

The Good News Story

19%

25%

31% 30%

10%

15%

23%

15%

Low Social Support

Depressive Symptoms

Perceived Stress

Anxiety

Baseline

18% 17%

13% 13% 12% 13% 16%

14%

Low Social Support

Depressive Symptoms

Perceived Stress

Anxiety

4 Months Postpartum CenteringPregnancy Prenatal Educa<on

The Good News Story

87%

67% 73% 73%

48% 44%

Nutri/on Info Smoking Info Alcohol Info

4 Months Postpartum CenteringPregnancy Prenatal Educa<on

Room to Improve

58%

74%

23% 18% 19%

85%

7% 12%

Smoked Since Birth BreasZeeding at 4 Months

Solid Food at 4 Months

Low Social Support

4 Months Postpartum CenteringPregnancy

Prenatal Educa<on



14-01-27

5

Questions

Ø What Questions Do You Have?

References Ø  Alberta Health Services. (2009). Demographics: demographic

information of diverse populations. Healthy Diverse Populations, Alberta Health Services – Calgary Health Region.

Ø  Alexander, G.R., Kotelchuk, M. (2001). Assessing the role and effectiveness of prenatal care: history, challenges and directions for future research. Public Health Rep, 116(4), 306-‐316

Ø  Al-‐Sahab, B., Heifetz, M., Tamim, H., Bohr, Y., & Connolly, J. (2012). Prevalence and characteristics of teen motherhood in Canada. Maternal & Child Health Journal, 16, 228-‐234.

Ø  Anderson, P.J., De Luca, C.R., Hutchinson, E., Spencer-‐Smith, M.M., Roberts, G., Doyle, L.W. (2011). Attention problems in a representative sample of extremely preterm/extremely low birth weight children. Developmental Neuropsychology, 36(1), 57-‐73.

Ø  Baldwin, K. A. (2006). Comparison of selected outcomes of CenteringPregnancy versus traditional prenatal care. Journal of Midwifery & Women's Health, 51, 266-‐272.

Ø  Bayrampour, H. & Heaman, M. (2011). Comparison of demographic and obstetric characteristics of Canadian primiparous women of advanced maternal age and younger age. Journal of Obstetrics & Gynaecology Canada: JOGC, 33, 820-‐829.

Ø  Brown, S.J., Yelland, J.S., Sutherland, G.A., Baghurst, P.A., Robinson, J.S. (2011). Stressful life events, social health issues and low birthweight in an Australian population-‐based birth cohort: challenges and opportunities in antenatal care. BMC Public Health, 11(196), 1-‐12.

Ø  Cameron, M. (1993). Prenatal care: a small investment begets a big return. Business & Health, 11(6), 50.

Ø  Carlson, N.S., Lowe, N.K. (2006). CenteringPregnancy: A new approach in prenatal care. MCN, 31(4), 218-‐223.

Ø  Carroli, G., Villar, J., Piaggio, G., Khan-‐Neelofur, D., Gülmezoglu, M., Mugford, M., Lumbiganon, P., Farnot, U., Bersgjø, P., WHO Antenatal Care Trial Research Group. (2001). WHO systematic review of randomized controlled trials of routine antenatal care. The Lancet, 5(19), 1565-‐1570.

Ø  Cohen, S., Kamarck, T., Mermelstein, R. (1983). A global measure of perceived stress. J Health Soc Behav, 24(4),385-‐396.

Ø  Coleman, B. L., Gutmanis, I., Larsen, L. L., Leffley, A. C., McKillop, J. M., & Rietdyk, A. E. (2009). Introduction of solid foods: do mothers follow recommendations? Canadian Journal of Dietetic Practice & Research, 70, 135-‐140.

Ø  Collins, J.W., Rankin, K.M., David, R.J. (2011). African American women's lifetime upward mobility and preterm birth: the effect of fetal programming. American Journal of Public Health, 101(4), 714-‐719.

Ø  Conrad, B., Gross, D., Fogg, L., Ruchala, P. (1992). Maternal confidence, knowledge and quality of mother-‐toddler interactions: a preliminary study. Infant Mental Health Journal, 13(4), 353-‐362.

Ø  Cox, J.L., Holden, J.M., Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-‐item Edinburgh Postnatal Depression Scale. Br J Psychiatry, 150,782-‐786.

Ø  Elder, G.H. (1998). The life course as developmental theory. Child development, 69, 1-‐12

Ø  Dyson, L., McCormick, F. M., & Renfrew, M. J. (2008). Interventions for promoting the initiation of breastfeeding. Cochrane Database of Systematic Reviews.

Ø  Feinberg, M. E. & Kan, M. L. (2008). Establishing family foundations: intervention effects on coparenting, parent/infant well-‐being, and parent-‐child relations. Journal of Family Psychology, 22, 253-‐263.

References Ø  Feinberg, M. E., Kan, M. L., & Goslin, M. C. (2009). Enhancing

coparenting, parenting, and child self-‐regulation: effects of family foundations 1 year after birth. Prevention Science, 10, 276-‐285.

Ø  Forster, D. A., McLachlan, H. L., & Lumley, J. (2006). Factors associated with breastfeeding at six months postpartum in a group of Australian women. International Breastfeeding Journal, 1, 18.

Ø  Gagnon, A. J. & Sandall, J. (2007). Individual or group antenatal education for childbirth or parenthood, or both. Cochrane Database of Systematic Reviews. 10.1002/14651858.CD002869.pub2.

Ø  Gao, L. L., Chan, S. W., Li, X., Chen, S., & Hao, Y. (2010). Evaluation of an interpersonal-‐psychotherapy-‐oriented childbirth education programme for Chinese first-‐time childbearing women: a randomised controlled trial. International Journal of Nursing Studies, 47, 1208-‐1216.

Ø  Gao, L. L., Chan, S. W., & Sun, K. (2012). Effects of an interpersonal-‐psychotherapy-‐oriented childbirth education programme for Chinese first-‐time childbearing women at 3-‐month follow up: randomised controlled trial. International Journal of Nursing Studies, 49, 274-‐281.

Ø  Glasheen, C., Richardson, G.A., Fabio, A. (2010). A systematic review of the effects of postnatal maternal anxiety on children. Archives of Women's Health, 13, 61-‐74.

Ø  Glink, P., Altfield, S. (2000). Engaging, educating and empowering young mothers: the Chicago doula project. Zero to Three, 20(3), 41-‐44.

Ø  Glor, E.D. (1987). Impacts of a prenatal program for native women. Canadian Journal of Public Health, 78(4), 249-‐254.

Ø  Grady, M. A. & Bloom, K. C. (2004). Pregnancy outcomes of adolescents enrolled in a CenteringPregnancy program. Journal of Midwifery & Women's Health, 49, 412-‐420.

Ø  Hall, M.H. (2001). Rationalization of antenatal care. The Lancet, 357, 1546.

Ø  Hesselink, A.E., van Poppel, M.N., van Eijsden, M., Twisk, J.W.R, van der Wal, Marcel, F. (2011). The effectiveness of a perinatal education programme on smoking, infant care, and psychosocial health for ethnic Turkish women. Midwifery 2011, 4(5) Article in Press.

Ø  Ickovics, J. R., Kershaw, T. S., Westdahl, C., Magriples, U., Massey, Z., Reynolds, H. et al. (2007). Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstet Gynecol, 110, 330-‐339.

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Ø  Ickovics, J. R., Reed, E., Magriples, U., Westdahl, C., Schindler, R. S., & Kershaw, T. S. (2011). Effects of group prenatal care on psychosocial risk in pregnancy: results from a randomised controlled trial. Psychol Health, 26, 235-‐250.

Ø  Johnston-‐Robledo, I. (1998). Beyond Lamaze: socioeconomic status and women's experiences with childbirth preparation. Journal of Gender, Culture, and Health, 3, 159-‐169.

Ø  Karacam, Z., Ancel, G. (2009). Depression, anxiety and influencing factors in pregnancy: a study in a turkish population. Midwifery, 25, 344-‐356.

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provide routine antenatal care for low-‐ risk women, and how often? A systematic review of randomized controlled trials. Paediatric and Perinatal Epidemiology, 12(Suppl. 2.), 7-‐26.

Ø  Kennedy, H. P., Farrell, T., Paden, R., Hill, S., Jolivet, R. R., Cooper, B. A. et al. (2011). A randomized clinical trial of group prenatal care in two military settings. Mil Med, 176, 1169-‐1177.

Ø  Klima, C. (2003). CenteringPregnancy: a model for pregnant adolescents. American College of Nurse-‐Midwives. 48(3), 220-‐225.

Ø  Klima, C., Norr, K., Vonderheid, S., & Handler, A. (2009). Introduction of CenteringPregnancy in a public health clinic. Journal of Midwifery & Women's Health, 54, 27-‐34.

Ø  Krans, E.E., Davis, M.M. (2011). Preventing low birthweight: 25 years, prenatal risk, and the failure to reinvent prenatal care. American Journal of Obstetrics and Gynecology, July, 1-‐6.

Ø  Leger-‐Leblanc, G. & Rioux, F. M. (2008). Effect of a prenatal nutritional intervention program on initiation and duration of breastfeeding. Canadian Journal of Dietetic Practice & Research, 69, 101-‐105.

Ø  Lineberger MR. (1987). Pregnant adolescents attending prenatal parent education classes: self-‐concept, anxiety and depression levels. Adolescence, 22(85), 179-‐193.

Ø  Liu, N., Mao, L., Sun, X., Liu, L., Yao, P., & Chen, B. (2009). The effect of health and nutrition education intervention on women's postpartum beliefs and practices: a randomized controlled trial. BMC Public Health, 9, 45.

Ø  Lu, M. C., Prentice, J., Yu, S. M., Inkelas, M., Lange, L. O., & Halfon, N. (2003). Childbirth education classes: sociodemographic disparities in attendance and the association of attendance with breastfeeding initiation. Maternal & Child Health Journal, 7, 87-‐93.

Ø  Massey, Z., Rising, S. S., & Ickovics, J. (2006). CenteringPregnancy group prenatal care: promoting relationship-‐centered care. J Obstet Gynecol Neonatal Nurs, 35, 286-‐294.

Ø  McCormick, M.C. (2001). Prenatal care-‐ necessary but not sufficient. Health Services Research, 36(2), 399-‐403.

Ø  McLaughlin, F.J., Altemeier, W.A., Christensen, M.J., Sherrod, K.B., Dietrich, M.S., Stern, D.T.

Ø  (1992). Randomized trial of comprehensive prenatal care for low-‐income women: effect

Ø  on infant birth weight. Pediatrics, 89, 128-‐132. Ø  McNeil, D.A., Vekved, M., Dolan, S.M., Seiver, J., Horn, S., Tough,

S.C. (2011). Getting more than they thought they needed: a qualitative study of women’s experience of group prenatal care. Social Science and Medicine, Submitted August 2011.

Ø  Novick, G. (2004). CenteringPregnancy and the current state of prenatal care. Journal of Midwifery and Women's Health, 49(5), 405-‐411.

Ø  Public Health Agency of Canada (2009). What Mothers Say: The Canadian Maternity Experiences Survey. Ottawa, ON: Public Health Agency of Canada.

Ø  Reid J. (2007). CenteringPregnancy: a model for group prenatal care. Nursing: Womens Health, 11(4), 382-‐388.

Ø  Rising, S.S. (1998). CenteringPregnancy: an interdisciplinary model of empowerment. Journal of Nursing, 2(43), 46-‐54.

Ø  Rising, S. S., Kennedy, H. P., & Klima, C. S. (2004). Redesigning prenatal care through CenteringPregnancy. J Midwifery Womens Health, 49, 398-‐404.

Ø  Robertson, B., Aycock, D. M., & Darnell, L. A. (2009). Comparison of Centering Pregnancy to traditional care in Hispanic mothers. Maternal & Child Health Journal, 13, 407-‐414.

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prenatal courses lead to heavier babies? American Journal of Public Health, 75, 1186-‐1189.

Ø  Roig, A. O., Martinez, M. R., Garcia, J. C., Hoyos, S. P., Navidad, G. L., Alvarez, J. C. et al. (2010). Factors associated to breastfeeding cessation before 6 months. Revista Latino-‐Americana de Enfermagem, 18, 373-‐380.

Ø  Rosen, I.M., Krueger, M.V., Carney, L.M., Graham, J.A. (2008). Prenatal breastfeeding education and breastfeeding outcomes. MCN, 33(5), 315-‐319.

Ø  Ruiz-‐Mirazo, E., Lopez-‐Yarto, M., McDonald, S. (2012). Group prenatal care versus individual prenatal care: a systematic review and meta-‐analyses. J Obstet Gynaecol. 34(3), 223-‐229.

Ø  Schuurmans, N., Gagne, J. P., Ezzat, A., Colliton, I., MacKinnon, C. J., Dushinski, B. et al. (1995). Healthy Beginnings: Guidelines for Care During Pregnancy and Childbirth. (Rep. No. No. 71). Toronto, Canada: Society of Obstetricians and Gynaecologists of Canada.

Ø  Sherbourne, C.D., Stewart, A.L. (1991). The MOS social support survey. Soc Sci Med, 32(6),705-‐714.

Ø  Shakespear, K., Waite, P. J., & Gast, J. (2010). A comparison of health behaviors of women in Centering Pregnancy and traditional prenatal care. Maternal & Child Health Journal, 14, 202-‐208.

Ø  Spielberger, C., Gorsuch, R. (1970). Test Manual for the State-‐Trait Anxiety Inventory. Palo Alto, California: Consulting Psychologist's Press;

Ø  Tough, S.C., Siever, J.E., Leew, S., Johnston, D.W., Benzies, K., Clark, D. (2008). Maternal mental health predicts risk of developmental problems at 3 years of age: follow up of a community based trial. BMC Pregnancy and Childbirth, 8(16). DOI: 10.1186/1471-‐2393-‐8-‐16.

Ø  Van den Bergh, B.R.H., Mulder, E.J.H., Mennes, M., Glover, V. (2005). Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child: links and possible mechanisms. A review. Neuroscience and Biobehavioral Reviews, 29, 237-‐258.

Ø  Villar, J., Ba'aqeel, H., Piaggio, G., Lumbiganon, P., Belizán, J.M., Farnot, U., Al-‐Mazrou, Y., Carroli, G., Pinol, A., Donner, A., Langer, A., Nigenda, G., Mugford, M., Fox-‐Rushby, J., Hutton, G., Bergsjø, P., Bakketeig, L., Berendes H. (2001). WHO antenatal care randomized trial for the evaluation of a new model of routine antenatal care. The Lancet, 357, 1551-‐1564.

Ø  Vintzileos, A.M., Ananth, C.V., Smulian, J.C., Scorza, W.E., Knuppel, R.A. (2002). Prenatal care and black-‐white fetal death disparity in the United States: hetergeneity by high-‐risk conditions. Obstetrics and Gynecology, 99(3), 483-‐489.

Ø  Walker, D. S. & Worrell, R. (2008). Promoting healthy pregnancies through perinatal groups: a comparison of CenteringPregnancy group prenatal care and childbirth education classes. Journal of Perinatal Education, 17, 27-‐34.

Ø  Weiner, E.A., Billamay, S., Partridge, J.C., Martinez, A.M. (2011). Antenatal education for expectant mothers results in sustained improvement in knowledge of newborn care. Journal of Perinatology, 31, 92-‐97.

Ø  World Health Organization. World Health Organization’s Infant Feeding Recommendation. [Cited 2012 April 5. Available from: http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/index.html

Contact Information

Suzanne Tough, PhD

[email protected] www.ucalgary.ca/stough

www.research4children.com

Ingunn Benediktsson, BHSc [email protected]



Presentation Title Effect of Folic Acid Food Fortification on the Birth Prevalence of Congenital Heart Defects Author #1 Shiliang Liu Surveillance and Analysis Division Public Health Agency of Canada

Author #2 KS Joseph Department of Obstetrics and Gynaecology, and the School of Population and Public Health University of British Columbia

Author #3 Jane Evans University of Manitoba

Author #4 Wei Luo Surveillance and Analysis Division Public Health Agency of Canada

Author #5 Michael Van den Hof Dalhousie University

Author #6 Julian Little Department of Epidemiology and Community Medicine University of Ottawa

Author #7 Michael S. Kramer Departments of Pediatrics, and of Epidemiology, Biostatistics and Occupational Healht McGill University

Author #8 Reg Sauve Departments of Pediatrics and Community Health Sciences University of Calgary

Abstract Background: Previous studies including one randomized clinical trial, and one population-‐based observational study have demonstrated a strong preventive effect of folic acid on congenital heart disease (CHD), especially severe CHD. We attempted to comprehensively assess and quantify the effect of folic acid food fortification on severe CHDs in Canada. Methods: The study population included all live births, stillbirths (N=5,554,076), and CHD cases diagnosed at the birth and in infancy in Canada (except Quebec and Manitoba) from 1990 to 2010. Data were compared between two time periods, i.e, before folic acid food fortification (1990-‐1998) and after (1999-‐2010). Changes in the birth prevalence of conotruncal, non-‐conotruncal and non-‐severe CHD over the two periods were estimated with Poisson regression after controlling for trends in maternal age, termination of pregnancy (TOP), multi-‐fetal pregnancy and pre-‐existing diabetes. Results: The birth prevalence rates of severe conotruncal, non-‐conotruncal, and non-‐severe CHD declined from 1.46, 0.95, and 12.6 per total 1000 births before fortification to 1.09, 0.82 and 12.0 per 1000 total births after fortification, respectively, with reductions of 25.3%, 13.5% and 4.8%, respectively (all p<0.001). After adjustment, the reductions in the 3 CHD rates were: -‐17.3% (p<0.001), 1.8% (p=0.79), and -‐0.8% (p=0.64), respectively. Changes in maternal age, TOP, and diabetes also played a significant role in influencing the temporal trends in the three CHD types.



C2ii Standard Lecture | New Research Effect of Folic Acid Food Fortification on the Birth Prevalence of Congenital Heart DefectsShiliang Liu

Conclusion: Food fortification with folic acid has contributed to reducing the birth prevalence of CHD, especially the birth prevalence of severe conotruncal CHDs. Learning objectives: 1. To assess and quantify the effect of folic acid food fortification on severe CHDs in Canada; 2. To examine the influence of maternal characteristics/factors on the temporal trends; 3. To promote multivitamin supplementation and fortification of grain products with folic acid. Biographies Dr. Shiliang Liu is a perinatal epidemiologist/research scientist with Public Health Agency of Canada. His primary research interest involves reproductive, maternal and perinatal/paediatric epidemiology.



Hillary L. McBride, Janelle L. Kwee, and Lori Wolfe

Introduction

Pregnancy, birth, and the ensuing identity transitions of motherhood impact women holistically. Perinatal experiences can lead to significant personal growth for women, yet are also associated with heightened vulnerability to traumatic stress and depression. Approximately 17 out of 20 postpartum women report emotional distress, one in five experience postpartum depression, and one in twenty new mothers meets diagnostic criteria for posttraumatic stress disorder following childbirth. Negative pregnancy, birth, and postpartum experiences not only impact the mental health of women, but also compromise mothers’ ability to nurture thriving mother-‐infant attachment relationships. Practices in prenatal care, labour and delivery, particularly as they affect the quality of a mother’s relationship with her health care providers, have a powerful impact on a woman’s experience of herself and her body (Redshaw & Van den Akker, 2008). This experience ultimately impacts a mother’s ability to nurture and build a strong attachment with her infant.

A Rationale for Integrating Care

While women’s emotional needs in pregnancy, birth, and postpartum adjustment are evident, perinatal health care providers, whose focus is on medical outcomes, have reported being inadequately prepared to address emotional aspects of maternal care. Thus, women do not systematically receive education, screening, and care for emotional needs in pregnancy, birth, and the postpartum period. Access to traditional, compartmentalized psychological services benefits only a small subsection of perinatal women, often in an untimely manner.

Psychological services, integrated into routine perinatal care, can improve both medical and psychological outcomes (Griffiths & Barker-‐Collo, 2008; Saisto et. al, 2006; Williams, Zolotor & Kauffman, 2011) for new and expecting mothers, support providers in delivering optimal care, and ultimately promote positive maternal and infant health outcomes. Ultimately, the needs of women in perinatal care make up shared turf between medical and mental health professionals. Brown, Mills, McCalmont, & Lees (2009) call for seamless partnerships between maternity and mental health services, specialist mental health teams in each maternity network, and clear referral pathways and criteria. It is imperative that we embrace an attitude of cooperation with the shared goal of promoting women’s health, and that we effectively cooperate within this shared territory of responsibility. Having trained mental health professionals be part of integrated maternity care teams would offset total medical costs by freeing medical providers to focus on their area of expertise and reducing the number of costly medical interventions utilized, particularly in labour and delivery.

“Outside the Box” Models of Care

What does collaborative, multidisciplinary, and integrated perinatal care look like in practice? In the last decade, there have been major advances in establishing effective models of integrated behavioural health care in primary care settings, which have documented benefits for patients and providers. These frameworks provide the basis



C2iii Standard Lecture | New Research Meeting Psychosocial Needs in Perinatal Care: Models for Multidisciplinary CollaborationHillary McBride, Janelle Kwee, Lori Wolfe



for specialty models of integrated perinatal care. There are some existing programs, such as the Maternal Mental Health Program, which is a shared care program bringing that co-‐locates multidisciplinary clinicians within a primary care setting in Canada, which is reported to have multiple positive outcomes for patients and providers in streamlining access to care (Bowen et. al 2008). There are several specific tasks that a mental health clinician could fulfill in an integrated care setting, including mental health “check-‐ups”, psycho-‐education, training and consultation for primary care providers, hypnobirthing training, screening and assessment, birth preparation and debriefing, and various modalities of mental health treatment, emotional support, and behavioural health consultation.

• Mental Health “Check Ups.” Routine pregnancy and postpartum visits with mental health professionals can be structured into the scope of perinatal services. These visits provide the opportunity for women to connect to personal and social aspects of their perinatal experience, to experience being cared for in a holistic way, to identify ways to improve their well-‐being, to identify concerns and risk factors, and to prepare mentally and emotionally for birth and motherhood.

• Creative Dissemination of Psycho-‐Educational Information. Women should have ready access to materials providing information related to their physical and psychosocial wellbeing during the perinatal period. There are multiple effective ways to “give psychology away” through creative methods of dissemination of psychoeducational information. Women are routinely educated about topics such as nutrition and exercise recommendations in pregnancy. Why not offer information about mental hygiene in pregnancy, birth, and motherhood? Podcasts in the waiting room, posters, flyers, and apps for one’s smartphone are all viable methods to support women with information that will help them take responsibility for their health and wellbeing, ask relevant questions, and seek help when needed.

• Training and Consultation for Maternity Care Providers. When psychological services are integrated into a primary care setting, it is not always clear who the “client” is, and this is rightly so. One of the primary functions of the primary care psychologist, or behavioural health consultant, is to provide informational support and consultation to the primary care providers directly. This allows providers of different areas of expertise to share the burden of responsibility in providing care, and reduces the stress for care providers facing problems outside of their expertise.

• Hypnobirthing Training. As discussed earlier, hypnobirthing is a specific application of hypnosis that can be helpful in reducing discomfort and medical complications and increasing satisfaction, while sometimes shortening the process of labor. Trained clinical hypnotherapists can prepare pregnant women to use hypnosis for birth and may provide “on call” hypnobirthing services to women during labour and delivery.

• Routine Assessment and Screening. Early detection and early intervention for mental health concerns yields the best prognosis. Primary maternity care providers are already occupied with monitoring a plethora of medical screening outcomes throughout the whole perinatal period. In an integrated care setting, the mental health professional would oversee collection, scoring, interpreting, and informing care



through routine assessment measures such as the Beck Depression Inventory, or the Edinburgh Postnatal Depression Scale.

• Debriefing. Seemingly so simple, being able to tell one’s story, in its intensity and with a sense of personal importance, reduces the risk of developing PTSD and helps women make sense of and value their unique experiences in pregnancy, birth, and postpartum. Having a meeting, either at the hospital or woman’s home, which is focused sharing and hearing the woman’s “birth story” is an example of how mental health provider can provide the opportunity for a woman to formally debrief her experience.

• Treatment, Support, and Consultation in Various Modalities. The earlier discussion of evidence-‐based interventions for perinatal psychosocial care offers numerous examples of ways that the integrated perinatal mental health specialist can offer relevant services within integrated maternity practices. Various modalities including individual and group approaches, structured and unstructured approaches, and mindfulness and relaxation training, are all viable methods for providing psychosocial support for perinatal women. An integrated mental health professional can be available to provide care pre-‐ and post-‐natally, and even during labour and delivery with an intervention such as hypnobirthing support. There are endless possibilities for creative synergies in a women-‐centered, multidisciplinary team.

The South Community Birth Program in Vancouver, BC

The South Community Birth Program (SCBP) in Vancouver, BC, is an innovative collaborative maternity program designed to best support women during pregnancy, birth, and the new-‐born period. Located in an underserved area of Vancouver, SCBP is the first of its kind in Canada; where family physicians, midwives, community health nurses, and doulas come together to provide woman-‐centred support. Since its inception in 2003, SCBP has helped to support more than 2000 women, with an average of 40 births a month. The SCBP team also offers the unique approach of ‘group care’, in which women and their partners can join together regularly to learn along side others during pregnancy on topics like doula support, nutrition, breastfeeding and birth. There is also a postpartum drop in clinic, where women up to 6 months postpartum can come together weekly to learn and stay connected with other new moms.

In spite of the wide array of supportive and women-‐centered services at SCBP, care providers still described a “felt need” for specialty mental health care, particularly for individual counselling. Presenting problems of anxiety, depression, and trauma were being addressed by the postpartum care nurse and referrals to Reproductive Mental Health at Women’s and Children’s Hospital. In the case of the latter, wait lists were often several months long, and referrals to Reproductive Mental Health potentially cared a stigma around emotional distress in a way that services from an “in house” provider on the same care team may not. In May of 2013, SCBP incorporated a clinical counselling intern from Trinity Western University into their provider team. The counselling intern provides direct services through individual and couple therapy, pre-‐ and post-‐natal groups, and co-‐therapy with the postpartum care nurse.

Consistent with the literature suggesting benefits not only for patients but providers, care providers at SCBP report “lighter” appointments with their patients who are connected to the counselling intern; they are able to do better what they are trained to do while the patients’ needs are being met more comprehensively through others



on the team. Anecdotal reports from the site suggest that other benefits include patient satisfaction and buy-‐in (“the clients love it, like they love having a lactation consultant; they want a team approach and to have this component in their health care” –Lori Wolfe), reduced waiting time for patients for counselling (they regularly get a first appointment within a week), cross-‐education between professions through case consultations and co-‐therapy.



C3i Standard Lecture | New Research

Temporal Trends in the Birth Prevalence of Congenital Anomalies in British Columbia, Canada, 2000 to 2011K.S. Joseph

Presentation Title Temporal Trends in the Birth Prevalence of Congenital Anomalies in British Columbia, Canada, 2000 to 2011 Authors K.S. Joseph MD, PhD Professor Department of Obstetrics & Gynaecology School of Population and Public Health University of British Columbia and the Children's and Women's Hospital of British Columbia

Amy Metcalfe Department of Obstetrics and Gynaecology, University of British Columbia

Brooke Kinniburgh Perinatal Services BC, Provincial Health Services Authority

Yasser Sabr School of Population and Public Health, University of British Columbia and the Department of Obstetrics and Gynaecology , College of Medicine, King Saud University, Riyadh, Saudi Arabia

Sylvie Langlois Perinatal Services BC and the Department of Medical Genetics, University of British Columbia

Alain Gagnon Department of Obstetrics and Gynaecology, University of British Columbia

Abstract Objective: Congenital anomaly surveillance serves an important public health function by identifying spatio-temporal changes in the distribution of specific congenital anomalies. We quantified the birth prevalence of congenital anomalies in British Columbia, Canada, between 2000 and 2011. Methods: Data on all live births and stillbirths were obtained from the British Columbia Perinatal Database Registry for the period April 2000 to March 2012. Temporal trends were assessed in rates of congenital anomalies among all live births and stillbirths. Results: Congenital anomalies occurred among 45 to 55 per 1000 live/total births and 5.0% of congenital anomaly births followed pregnancy termination. There was a temporal decrease in the birth prevalence of congenital anomalies overall, while the rate of congenital anomaly births following pregnancy termination increased. The following changes in birth prevalence were observed within specific congenital anomaly subgroups:

a) Circulatory system anomalies (including ventricular septal defects), musculoskeletal anomalies and anomalies of the eyes, ears, face and neck decreased.

b) Central nervous system (including microcephaly), gastrointestinal (including ankyloglossia) and urinary anomalies increased.

c) Multiple congenital anomalies decreased among live births, while births following pregnancy termination for multiple congenital anomalies increased.

d) Gastroschisis showed a decrease among live births, total births and terminations. e) Congenital diaphragmatic hernia, Down syndrome, Trisomy 13 and 18, spina bifida, atrial septal

defects, and hypoplastic left heart syndrome showed no temporal trends. Interpretation: The birth prevalence of congenital anomalies in British Columbia follows expected patterns. However, an investigation into the increase in the birth prevalence of microcephaly is required.



Learning Objectives 1. To describe temporal changes in the birth prevalence of congenital anomalies in British Columbia. 2. To determine if any specific congenital anomaly subtypes show increasing trends that may require a

focused investigation to rule out errors in diagnosis or coding. 3. To determine if the live birth prevalence of specific congenital anomaly subtypes shows the

expected decreasing temporal pattern (especially in relation to increases in prenatal diagnosis and pregnancy termination and folic acid fortification of food).

Synopsis Congenital anomaly surveillance in British Columbia showed that the overall birth prevalence of congenital anomalies decreased between 2000 and 2011, while births following pregnancy termination for congenital anomalies increased. The birth prevalence of microcephaly increased and this requires further investigation to clarify its cause and significance.

Author #1 Shaw D Vice President BC Women's Hospital

Author #2 Norman WV Assistant Professor UBC

Abstract Recent advances in knowledge in both developing and the developed world have greatly enhanced our understanding of birth spacing. Current evidence will be presented for a wide range of topics including: Ideal inter-‐pregnancy intervals, effects of shorter and longer intervals on a myriad of pregnancy, birth, developmental, societal and economic outcomes, and the real life effectiveness of the range of modern and traditional contraceptive methods available. Bring your questions and ideas as a lively discussion is likely to ensue! Learning objectives 1. Describe the benefits of ideal inter-‐pregnancy intervals in developed and developing world settings 2. Understand approaches to contraception counselling that include considerations of the woman, her context, culture and goals. 3. List effectiveness and typical adherence of modern and traditional contraception methods.

Synopsis Current evidence will be presented for a wide range of topics including: Ideal inter-‐pregnancy intervals (IPI); effects of IPI on pre-‐term birth, developmental and societal outcomes; and the real life effectiveness of contraceptive methods available. Bring your questions and ideas as a lively discussion is likely to ensue! Biographies Dorothy Shaw is the Vice President, Medical Affairs for British Columbia’s Women’s Hospital, responsible for quality and safety in patient care using patient-‐centred, cost-‐effective approaches. She is a Clinical Professor in the Departments of Obstetrics and Gynaecology and Medical Genetics at UBC. Dr. Shaw was the first woman President of the International Federation of Gynecology and Obstetrics. She is a spokesperson for the Partnership for Maternal Newborn Child Health (MNCH) and currently chairs the Canadian Network on MNCH in a volunteer capacity. Dr. Wendy Norman has been a family physician since 1985, with a family planning focused practice since 1997. She is an Assistant Professor, and Director, Clinician Scholars Program in the Department of Family Practice, UBC. Dr. Norman founded and co-‐leads the national collaboration: Contraception Access Research Team/Groupe de recherche sur l’accessibilité à la contraception. Norman’s research program seeks to develop evidence to support improvements to family planning access, quality of care, and health policy.



C3ii Standard Lecture | Quality Improvement Baby’s Best Chance: What is the Best Evidence on Inter-pregnancy Intervals and Effective Birth Spacing Techniques?Dorothy Shaw, Wendy Norman

Authors: Lynn Farrales, MSc, MD, CCFP, Still Life Canada Jennifer Douglas, PhD, Still Life Canada Andrea Regimbal, BSc, MSc, Still Life Canada Jaime Ascher, BSc, Still Life Canada John Nanson, MEd, Still Life Canada Andrea McComb, PhD(c), Still Life Canada May Farrales, PhD (c), Still Life Canada

Alena Astashenkava, Still Life Canada Peter DeLind, Still Life Canada Michael Klein, MD FAAP CCFP FCPS, University of British Columbia Shafik Dharamsi, PhD, University of British Columbia Christine Jonas-‐Simpson, RN PhD, York University Joanne Cacciatore, PhD LMSW FT, Arizona State University

Introduction This presentation reports on the initial findings of focus groups conducted with 27 bereaved parents. The presentation will discuss the context for the research, highlight the community-‐ and participatory-‐based nature of the research, and outline emergent themes derived from the initial data analysis. Learning objectives The conference participant will:

(1) develop an understanding of gaps in the care and support of bereaved parents of babies who were stillborn as suggested by the preliminary analysis of data collected during focus groups, and

(2) learn of the importance of conducting community-‐based collaborative research. Context Despite the 2.6 million stillbirths worldwide each year1 and the rising rate in British Columbia2 stillbirth continues to be a neglected public health issue3 and the associated grief remains invisible4,5. Only recently have the World Health Organization6 and professional bodies7 identified stillbirth as a priority area; in 2011, the authors of the Lancet Stillbirth Series urged countries, communities and individuals to decrease stillbirth rates, reduce the stigma associated with stillbirth and provide bereavement support for families8. In Canada, the lack of attention to stillbirth has left healthcare providers serving bereaved families with limited local research on which to draw9,10. Though initiatives to support families affected by pregnancy and infant loss exist in some Canadian cities, these efforts remain localized and without a specific focus on stillbirth, leaving many families without appropriate support and the topic of stillbirth in the shadows. Addressing bereavement support for parents after stillbirth in Canada is important not only because of global priorities8 and local trends2, but also because of the specialized needs of families affected by stillbirth. It has been suggested that ‘the grief of a stillbirth is unlike any other form of grief’11, and the devastation of stillbirth has been described as being the same as that following the death of a live-‐born child. However, unlike the grief following the death of a live-‐born child, the grief of stillbirth is disenfranchised and ambiguous4, 5, 12, 13, 14. The long-‐term psychological outcomes after stillbirth have been studied, with depression, anxiety and post-‐traumatic stress disorder being documented15, 16, 17. Recent studies have recommended the implementation of bereavement care training programs, establishment of community supports beyond the hospital, further research into effective bereavement care, and partnerships between medical professionals and parents to reduce stigma18.



C3iii Standard Lecture | New Research

Bereaved Parents Break the Silence of StillbirthLynn Farrales, Jennifer Douglas, Jaime Ascher, Andrea Regimbal

Still Life Canada – Stillbirth & Neonatal Death Education, Research and Support Society Still Life Canada (SLC) is a non-‐profit society whose mission is to build a community of support for anyone affected by stillbirth and neonatal death and to promote research to reduce both. SLC was formed by three bereaved families who met by chance after their babies were stillborn. The chance nature of their meeting is important, as it highlights the lack of organized and accessible support networks for parents of babies who were stillborn. The three families met at first to share their stories and help each other learn to grieve. Realizing the pressing need for a society dedicated to stillbirth education, research and support, the three families formed Still Life Canada and shortly thereafter planned a conference to bring other bereaved families together to share stories and begin to build a community of support. The You Are Not Alone: Bringing Stillbirth Out of the Shadows conference (which was supported by Perinatal Services BC and the Canadian Institute of Health Research in collaboration with SLC) was held on July 12-‐13, 2013 and was attended by bereaved parents and invited healthcare professionals. On the second day of the conference, parents were recruited to participate in focus groups. The focus groups (for which funding was received from the BC College of Family Practice) were intended to explore the experiences of participants as bereaved parents and to identify perceived gaps in services and supports. The three stated objectives of the focus group research were:

1) To explore the experiences of bereaved parents and identify gaps in services and supports; 2) To set groundwork for both collaborative and participatory research by engaging bereaved parents; and 3) To inform the provision of bereavement support by knowledge users, healthy policy around bereavement

care, and programs supporting trainees and staff in the provision of bereavement care. Community-‐based participatory research Community-‐based participatory research is characterized by close collaboration between researchers and communities; community members are involved in all stages of research from the identification of the research problem to the data collection and analysis19. The project described here is a prime example of community-‐based participatory research, with the community of bereaved parents involved at every step. The initiative and planning for the You Are Not Alone: Bringing Stillbirth Out of the Shadows conference came from the three bereaved families who founded SLC. During the planning of the conference, a broader research team was formed as some members of the founding SLC group formed partnerships with academic researchers at UBC and invited additional SLC members to participate in research initiatives. It is important to note that while the guidance and expertise of SLC’s academic partners were invaluable, the research continued to be driven by the bereaved parents and family members on the SLC Research Team. In consultation with academic partners, the bereaved family members of the Team set the objectives for the focus groups and determined the research questions. Recruitment of focus group participants, facilitation and observation of the focus groups, and analysis of the data collected have likewise been completed or are in the process of being completed by bereaved parents and families. Following the You Are Not Alone: Bringing Stillbirth Out of the Shadows conference, an SLC Research Committee consisting of members of the SLC Research Team was formed. The SLC Research Committee regularly reports to the SLC Board of Directors, and in January held a meeting to report to the Board of Directors and to other interested stakeholders (i.e., academic partners, invited healthcare professionals, SLC members). The newly-‐formed SLC Research Committee is now planning an Art Workshop, in collaboration with academic partners, for the attendees of the You Are Not Alone: Bringing Stillbirth Out of the Shadows conference as a way to disseminate some of the conference outcomes and build on the themes that emerged from the conference itself. This will contribute to the preparation of a conference report for distribution to stakeholders. The SLC Research Committee is committed to involving community members in all knowledge translation activities in order to ensure that research findings reflect as accurately as possible the community’s experiences.



Emergent themes from focus group research Four focus groups were conducted with 27 bereaved mothers and fathers. Analysis of the data collected through the focus groups is ongoing. Though we are continuing to analyze data and refine categories and themes, at this point we wish to highlight the theme or concept of acknowledgment, which appears to us to overarch and connect several other themes and categories. During the focus groups, bereaved parents spoke of – or intimated – the need for acknowledgment in many different respects., For example, they spoke of the need for acknowledgment of the baby as a child. Because this theme or concept of acknowledgment permeated various aspects of bereaved parents’ lives and experiences, it may have significant implications for informing supports and services for bereaved families. A key feature, of community-‐based participatory research is that the community is involved in all phases of the research process, and additional community consultation – with both our community of bereaved parents and with our academic partners – is required before the themes identified thus far can be accepted; such consultation is ongoing, and our conference presentation will report on progress to date. References: 1 Cousens S, Stanton C, Blencowe H, et al. (2011). National, regional, and worldwide estimates for stillbirth rates with trends since 1995: a

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