Disparities and Trends in Birth Outcomes, Perinatal and Infant Mortality in Aboriginal vs. Non-Aboriginal Populations: A Population-Based Study in Quebec, Canada 1996-2010

Population-based birth cohort study on diabetes in pregnancy and infant hospitalisations in Cree, other First Nations and non-Indigenous communities in Quebec

OBJECTIVES

Diabetes in pregnancy, whether pre-gestational (chronic) or gestational (de novo hyperglycaemia), increases the risk of adverse birth outcomes. It is unclear whether gestational diabetes increases the risk of postnatal morbidity in infants. Cree First Nations in Quebec are at high risk for diabetes in pregnancy. We assessed whether pre-gestational or gestational diabetes may increase infant hospitalisation (an infant morbidity indicator) incidence, and whether this may be related to more frequent infant hospitalisations in Cree and other First Nations in Quebec.

DESIGN

Population-based birth cohort study through administrative health data linkage.

SETTING AND PARTICIPANTS

Singleton infants (≤1 year) born to mothers in Cree (n=5070), other First Nations (9910) and non-Indigenous (48 200) communities in rural Quebec.

RESULTS

Both diabetes in pregnancy and infant hospitalisation rates were much higher comparing Cree (23.7% and 29.0%) and other First Nations (12.4% and 34.1%) to non-Indigenous (5.9% and 15.5%) communities. Compared with non-diabetes, pre-gestational diabetes was associated with an increased risk of any infant hospitalisation to a greater extent in Cree and other First Nations (relative risk (RR) 1.56 (95% CI 1.28 to 1.91)) than non-Indigenous (RR 1.26 (1.15 to 1.39)) communities. Pre-gestational diabetes was associated with increased risks of infant hospitalisation due to diseases of multiple systems in all communities. There were no significant associations between gestational diabetes and risks of infant hospitalisation in all communities. The population attributable risk fraction of infant hospitalisations (overall) for pre-gestational diabetes was 6.2% in Cree, 1.6% in other First Nations and 0.3% in non-Indigenous communities.

CONCLUSIONS

The study is the first to demonstrate that pre-gestational diabetes increases the risk of infant hospitalisation overall and due to diseases of multiple systems, but gestational diabetes does not. High prevalence of pre-gestational diabetes may partly account for the excess infant hospitalisations in Cree and other First Nations communities in Quebec.

Indigenous peoples and the COVID-19 pandemic: a systematic scoping review

Past influenza pandemics including the Spanish flu and H1N1 have disproportionately affected Indigenous Peoples. We conducted a systematic scoping review to provide an overview of the state of understanding of the experience of Indigenous peoples during the first 18 months of the COVID-19 pandemic, in doing so we capture the state of knowledge available to governments and decision makers for addressing the needs of Indigenous peoples in these early months of the pandemic. We addressed three questions: (a) How is COVID-19 impacting the health and livelihoods of Indigenous peoples, (b) What system level challenges are Indigenous peoples experiencing, (c) How are Indigenous peoples responding? We searched Web of Science, Scopus, and PubMed databases and UN organization websites for publications about Indigenous peoples and COVID-19. Results were analyzed using descriptive statistics and content analysis. A total of 153 publications were included: 140 peer-reviewed articles and 13 from UN organizations. Editorial/commentaries were the most (43%) frequent type of publication. Analysis identified Indigenous peoples from 19 different countries, although 56% of publications were centered upon those in Brazil, United States, and Canada. The majority (90%) of articles focused upon the general adult population, few (<2%) used a gender lens. A small number of articles documented COVID-19 testing (0.04%), incidence (18%), or mortality (16%). Five themes of system level challenges affecting exposure and livelihoods evolved: ecological, poverty, communication, education and health care services. Responses were formal and informal strategies from governments, Indigenous organizations and communities. A lack of ethnically disaggregated health data and a gender lens are constraining our knowledge, which is clustered around a limited number of Indigenous peoples in mostly high-income countries. Many Indigenous peoples have autonomously implemented their own coping strategies while government responses have been largely reactive and inadequate. To 'build back better' we must address these knowledge gaps.

Analysis of an Association between Preterm Birth and Parental Educational Level in Japan Using National Data

Preterm birth rate depending on parental educational level in recent years has not been surveyed in Japan. In this study, we showed the trend in preterm birth rate depending on parental educational level from 2000 to 2020 by linking data from the Census regarding individuals' educational level and parents in birth data of the vital statistics. Four types of parental educational level, namely junior high school, high school, technical school or junior college, and university or graduate school, were compared. Slope and relative indexes of inequality for preterm birth by educational level were computed by binomial models. Data on 3,148,711 births and 381,129,294 people were used in the analysis, and data on 782,536 singleton births were used after data linkage. The preterm birth rate (%) for junior high school graduate mothers and fathers was 5.09 and 5.20 in 2020, respectively. Contrarily, the preterm birth rate (%) for parents who graduated from a university or graduate school was 4.24 for mothers and 4.39 for fathers, and the rate tended to increase as educational level decreased, irrespective of parental gender. Results of inequality indexes showed that a statistically significant inequality by parental educational level persisted from 2000 to 2020.

An ecological approach to understanding Women's reproductive health and pregnancy decision making in Greenland

Using a community based participatory research framework and ecological systems theory we explored the experiences of reproductive health among Inuit women living in a remote Northwestern settlement in Greenland to understand the multiple diverse factors that influence their pregnancy outcomes. We conducted 15 in depth interviews with Inuit women between the ages of 19 and 45. Key factors influencing women's pregnancy decision making were: 1) precursors to pregnancy; 2) birth control use; 3) adoption and abortion; and 4) access to reproductive health care. Our results highlight the need to identify pathways through research, policy, health promotion, and health care practice that can support Inuit women in Greenland to be reproductively healthy and make informed decisions about pregnancy that resonate with their cultural beliefs as well as the realities of their everyday lives. We recommend the integration of cultural messaging into interdisciplinary approaches for preventive reproductive health care with women living in remote Arctic communities.

Academy of Breastfeeding Medicine Clinical Protocol #2: Guidelines for Birth Hospitalization Discharge of Breastfeeding Dyads, Revised 2022

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The Academy of Breastfeeding Medicine recognizes that not all lactating individuals identify as women. Using gender-inclusive language, however, is not possible in all languages and all countries and for all readers. The position of the Academy of Breastfeeding Medicine (https://doi.org/10.1089/bfm.2021.29188.abm) is to interpret clinical protocols within the framework of inclusivity of all breastfeeding, chestfeeding, and human milk-feeding individuals.

An unconditional prenatal income supplement is associated with improved birth and early childhood outcomes among First Nations children in Manitoba, Canada: a population-based cohort study

BACKGROUND

In Manitoba, Canada, low-income pregnant women are eligible for the Healthy Baby Prenatal Benefit, an unconditional income supplement of up to CAD $81/month, during their latter two trimesters. Our objective was to determine the impact of the Healthy Baby Prenatal Benefit on birth and early childhood outcomes among Manitoba First Nations women and their children.

METHODS

We used administrative data to identify low-income First Nations women who gave birth 2003-2011 (n = 8209), adjusting for differences between women who received (n = 6103) and did not receive the Healthy Baby Prenatal Benefit (n = 2106) with using propensity score weighting. Using multi-variable regressions, we compared rates of low birth weight, preterm, and small- and large-for-gestational-age births, 5-min Apgar scores, breastfeeding initiation, birth hospitalization length of stay, hospital readmissions, complete vaccination at age one and two, and developmental vulnerability in Kindergarten.

RESULTS

Women who received the benefit had lower risk of low birth weight (adjusted relative risk [aRR] 0.74; 95% CI 0.62-0.88) and preterm (aRR 0.77; 0.68-0.88) births, and were more likely to initiate breastfeeding (aRR 1.05; 1.01-1.09). Receipt of the Healthy Baby Prenatal Benefit was also associated with higher rates of child vaccination at age one (aRR 1.10; 1.06-1.14) and two (aRR 1.19; 1.13-1.25), and a lower risk that children would be vulnerable in the developmental domains of language and cognitive development (aRR 0.88; 0.79-0.98) and general knowledge/communication skills (aRR 0.87; 0.77-0.98) in Kindergarten.

CONCLUSIONS

A modest unconditional income supplement of CAD $81/month during pregnancy was associated with improved birth outcomes, increased vaccination rates, and better developmental health outcomes for First Nations children from low-income families.

Indigenous women's reproductive health in the Arctic zone of Western Siberia: challenges and solutions

In the Russian Arctic, alarming trends (shortage of nomadic Indigenous women, high reproductive loss, child mortality rates) indicate long-term changes towards demographic decline. This study aimed at comparing some indicators of the reproductive health (childbirth rates, number of pregnancies, pregnancy loss) of Indigenous and non-Indigenous women in the exploration of cultural and social factors influencing reproductive behaviour. A multidisciplinary approach draws on methods of medicine, sociology and health economics. It includes data of the women’s reproductive health collected from surveys of 879 women (of whom 627 were Indigenous) during expeditions to the settlements and the tundra of the Yamal-Nenets Autonomous Okrug in 2013–2019. In the tundra, 66.7% of registered Indigenous women’s pregnancies resulted in childbirth, 7.8% in induced abortions, 25.5% in spontaneous miscarriage. More than three children were delivered by 59.1% of Indigenous women. Most Indigenous families suffered from high pregnancy loss. Marriage between close relatives was 27.0%. Child mortality equalled 24.4%, three times higher than in the population of the settlements and eight times higher than in families immigrating from other regions. The survival of Indigenous peoples significantly depends on women’s reproductive health and sufficient medical service that requires targeted policy.

A review of health and wellness studies involving Inuit of Manitoba and Nunavut

The purpose of this review is to summarise past Inuit health and wellness studies in Manitoba and the Kivalliq region of Nunavut to provide a snapshot of the types of studies available and identify the gaps in knowledge. Research to date has largely been disease-based and often provides comparisons between Indigenous and non-Indigenous people. Distinct Inuit experiences are rarely written about from an Inuit perspective. However, Inuit Tapiriit Kanatami, the national organisation of Inuit in Canada, and Pauktuutit Inuit Women of Canada have been leaders in strengths-based community research and publications that address priorities determined by the Inuit, including the 2018 Inuit Tapiriit Kanatami document National Inuit Strategy on Research (132).

Diabetes in pregnancy in associations with perinatal and postneonatal mortality in First Nations and non-Indigenous populations in Quebec, Canada: population-based linked birth cohort study

OBJECTIVE

Both pregestational and gestational diabetes mellitus (PGDM, GDM) occur more frequently in First Nations (North American Indians) pregnant women than their non-Indigenous counterparts in Canada. We assessed whether the impacts of PGDM and GDM on perinatal and postneonatal mortality may differ in First Nations versus non-Indigenous populations.

DESIGN

A population-based linked birth cohort study.

SETTING AND PARTICIPANTS

17 090 First Nations and 217 760 non-Indigenous singleton births in 1996-2010, Quebec, Canada.

MAIN OUTCOME MEASURES

Relative risks (RR) of perinatal and postneonatal death. Perinatal deaths included stillbirths and neonatal (0-27 days of postnatal life) deaths; postneonatal deaths included infant deaths during 28-364 days of life.

RESULTS

PGDM and GDM occurred much more frequently in First Nations (3.9% and 10.7%, respectively) versus non-Indigenous (1.1% and 4.8%, respectively) pregnant women. PGDM was associated with an increased risk of perinatal death to a much greater extent in First Nations (RR=5.08[95% CI 2.99 to 8.62], p<0.001; absolute risk (AR)=21.6 [8.6-34.6] per 1000) than in non-Indigenous populations (RR=1.76[1.17, 2.66], p=0.003; AR=4.2[0.2, 8.1] per 1000). PGDM was associated with an increased risk of postneonatal death in non-Indigenous (RR=3.46[1.71, 6.99], p<0.001; AR=2.4[0.1, 4.8] per 1000) but not First Nations (RR=1.16[0.28, 4.77], p=0.35) infants. Adjusting for maternal and pregnancy characteristics, the associations were similar. GDM was not associated with perinatal or postneonatal death in both groups.

CONCLUSIONS

The study is the first to reveal that PGDM may increase the risk of perinatal death to a much greater extent in First Nations versus non-Indigenous populations, but may substantially increase the risk of postneonatal death in non-Indigenous infants only. The underlying causes are unclear and deserve further studies. We speculate that population differences in the quality of glycaemic control in diabetic pregnancies and/or genetic vulnerability to hyperglycaemia's fetal toxicity may be contributing factors.

Adverse birth outcomes and infant mortality according to registered First Nations status and First Nations community residence across Canada

OBJECTIVE

Studies of perinatal health outcomes in Canadian First Nations populations have largely focused on limited geographical areas and have been unable to examine outcomes by registered status and community residence. In this study, we compare rates of adverse birth outcomes among First Nations individuals living within vs. outside of First Nations communities and those with vs. without registered status.

METHODS

Data included 13,506 singleton pregnancies from the 2006 Canadian Birth-Census Cohort. Outcomes examined included preterm birth (PTB), small- and large-for-gestational-age birth (SGA, LGA), stillbirth, overall infant mortality, and neonatal and postneonatal mortality. Risk ratios (RRs) were estimated with adjustment for maternal age, education, parity, and paternal education.

RESULTS

Mothers living in First Nations communities and those with status had elevated adjusted risks of LGA (RR for First Nations community residence = 1.22, 95% CI = 1.09-1.35; RR for status = 1.50, 95% CI = 1.16-1.93). Rates of SGA were significantly lower among mothers with status (adjusted RR = 0.62, 95% CI = 0.44-0.86). Rates of PTB did not vary substantially by residence or by status. Adjusted differences in fatal outcomes could not be estimated, owing to small cell sizes. However, mothers living in First Nations communities had higher crude rates of infant mortality (10.9 vs. 7.7 per 1000), particularly for neonatal mortality (6.1 vs. 2.9).

CONCLUSION

Future investigations should explore risk factors, including food security and access to health care services, that may explain disparities in SGA and LGA by status and residence within First Nations populations.

Health social work in Canada: Five trends worth noting

Highlighting a strong human rights and social justice orientation underlying health social work in Canada, this paper describes recent contributions of Canadian health social work practitioners and scholars to five areas identified by Auslander (2001) in a delphi study of health social work in its first century. Five current 'trends' are discussed which correspond with Auslander's themes of professional legitimacy and scope, social causation, dissemination of knowledge, interventions, and cultural appropriateness. These trends are: 1) defining the scope of health social work practice; 2) addressing the social determinants of health; 3) promoting evidence-based practice in health social work; 4) delivering client and family-centered care; and 5) implementing cultural safety and trauma-informed practice. Suggestions are made to further strengthen the position of health social work in Canada.

Disparities in infant hospitalizations in Indigenous and non-Indigenous populations in Quebec, Canada

BACKGROUND

Infant mortality is higher in Indigenous than non-Indigenous populations, but comparable data on infant morbidity are lacking in Canada. We evaluated disparities in infant morbidities experienced by Indigenous populations in Canada.

METHODS

We used linked population-based birth and health administrative data from Quebec, Canada, to compare hospitalization rates, an indicator of severe morbidity, in First Nations, Inuit and non-Indigenous singleton infants (< 1 year) born between 1996 and 2010.

RESULTS

Our cohort included 19 770 First Nations, 3930 Inuit and 225 380 non-Indigenous infants. Compared with non-Indigenous infants, all-cause hospitalization rates were higher in First Nations infants (unadjusted risk ratio [RR] 2.05, 95% confidence interval [CI] 1.99-2.11; fully adjusted RR 1.43, 95% CI 1.37-1.50) and in Inuit infants (unadjusted RR 1.96, 95% CI 1.87-2.05; fully adjusted RR 1.37, 95% CI 1.24-1.52). Higher risks of hospitalization (accounting for multiple comparisons) were observed for First Nations infants in 12 of 16 disease categories and for Inuit infants in 7 of 16 disease categories. Maternal characteristics (age, education, marital status, parity, rural residence and Northern residence) partly explained the risk elevations, but maternal chronic illnesses and gestational complications had negligible influence overall. Acute bronchiolitis (risk difference v. non-Indigenous infants, First Nations 37.0 per 1000, Inuit 39.6 per 1000) and pneumonia (risk difference v. non-Indigenous infants, First Nations 41.2 per 1000, Inuit 61.3 per 1000) were the 2 leading causes of excess hospitalizations in Indigenous infants.

INTERPRETATION

First Nations and Inuit infants had substantially elevated burdens of hospitalizations as a result of diseases of multiple systems. The findings identify substantial unmet needs in disease prevention and medical care for Indigenous infants.

Causes and temporal changes in nationally collected stillbirth audit data in high-resource settings

Few high-income countries have an active national programme of stillbirth audit. From the three national programmes identified (UK, New Zealand, and the Netherlands) steady declines in annual stillbirth rates have been observed over the audit period between 1993 and 2014. Unexplained stillbirth remains the largest group in the classification of stillbirths, with a decline in intrapartum-related stillbirths, which could represent improvements in intrapartum care. All three national audits of stillbirths suggest that up to half of all reviewed stillbirths have elements of care that failed to follow standards and guidance. Variation in the classification of stillbirth, cause of death and frequency of risk factor groups limit our ability to draw meaningful conclusions as to the true scale of the burden and the changing epidemiology of stillbirths in high-income countries. International standardization of these would facilitate direct comparisons between countries. The observed declines in stillbirth rates over the period of perinatal audit, a possible consequence of recommendations for improved antenatal care, should serve to incentivise other countries to implement similar audit programmes.

Teen pregnancy in Inuit communities - gaps still needed to be filled

Teen pregnancy is depicted around the world as an important cause of health disparities both for the child and the mother. Accordingly, much effort has been invested in its prevention and led to its decline in the northern hemisphere since the mid-1990s. Despite that, high rates are still observed in the circumpolar regions. As Inuit communities have granted better understanding of teenage pregnancy a priority for the coming years, this article comprehensively reviews this multidimensional issue. By depicting current prevalence, likely determinants and possible impacts documented among Inuit of Canada, Alaska and Greenland, and contrasting them to common knowledge that has emerged from other populations over the years, great gaps surface. In some regions, the number of pregnancies per number of Inuit women aged between 15 and 19 years has increased since the turn of the millennium, while statistics from others are either absent or difficult to compare. Only few likely determinants of teenage pregnancy such as low education and some household factors have actually been recognized among Inuit populations. Documented impacts of early pregnancy on Inuit women and their children are also limited compared to those from other populations. As a way to better address early pregnancy in the circumpolar context, the defence for additional scientific efforts and the provision of culturally adapted sexual health prevention programmes appear critical.

Macrosomia, Perinatal and Infant Mortality in Cree Communities in Quebec, 1996-2010

BACKGROUND

Cree births in Quebec are characterized by the highest reported prevalence of macrosomia (~35%) in the world. It is unclear whether Cree births are at greater elevated risk of perinatal and infant mortality than other First Nations relative to non-Aboriginal births in Quebec, and if macrosomia may be related.

METHODS

This was a population-based retrospective birth cohort study using the linked birth-infant death database for singleton births to mothers from Cree (n = 5,340), other First Nations (n = 10,810) and non-Aboriginal (n = 229,960) communities in Quebec, 1996-2010. Community type was ascertained by residential postal code and municipality name. The primary outcomes were perinatal and infant mortality.

RESULTS

Macrosomia (birth weight for gestational age >90th percentile) was substantially more frequent in Cree (38.0%) and other First Nations (21.9%) vs non-Aboriginal (9.4%) communities. Comparing Cree and other First Nations vs non-Aboriginal communities, perinatal mortality rates were 1.52 (95% confidence intervals 1.17, 1.98) and 1.34 (1.10, 1.64) times higher, and infant mortality rates 2.27 (1.71, 3.02) and 1.49 (1.16, 1.91) times higher, respectively. The risk elevations in perinatal and infant death in Cree communities attenuated after adjusting for maternal characteristics (age, education, marital status, parity), but became greater after further adjustment for birth weight (small, appropriate, or large for gestational age).

CONCLUSIONS

Cree communities had greater risk elevations in perinatal and infant mortality than other First Nations relative to non-Aboriginal communities in Quebec. High prevalence of macrosomia did not explain the elevated risk of perinatal and infant mortality in Cree communities.